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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600526
Report Date: 06/01/2022
Date Signed: 06/01/2022 03:29:39 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211018110953
FACILITY NAME:ELDERS INN ON WEBSTERFACILITY NUMBER:
015600526
ADMINISTRATOR:MARIE ANN LAGASCAFACILITY TYPE:
740
ADDRESS:1721 WEBSTER STREETTELEPHONE:
(510) 521-9200
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:60CENSUS: 36DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Stephen Zimmerman, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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 Staff did not properly report an incident involving a resident while in care
INVESTIGATION FINDINGS:
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On 6/1/2022 at 11:15 AM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit, met with administrator Stephen Zimmerman, gathered information and delivered investigation finding to administrator. LPA explained the purpose of the visit.
During investigation, the Department interviewed staff, reviewed R1's file including but not limited to, admission agreement, list of medications, MAR, staff schedule, death report, and incident reports.
Based on LPA’s interview and records review, the facility failed to submit unusual incident report to CCL for R1’s fall on 9/12/2021, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211018110953

FACILITY NAME:ELDERS INN ON WEBSTERFACILITY NUMBER:
015600526
ADMINISTRATOR:MARIE ANN LAGASCAFACILITY TYPE:
740
ADDRESS:1721 WEBSTER STREETTELEPHONE:
(510) 521-9200
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:60CENSUS: 36DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Stephen Zimmerman, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Staff are not providing adequate care and supervision to the residents
Staff is sleeping in the common area
Staff are not properly trained to care for residents
Staff do not follow medical orders as required
INVESTIGATION FINDINGS:
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On 6/1/2022 at 11:15 AM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit, met with administrator Stephen Zimmerman, gathered information and delivered investigation finding to administrator. LPA explained the purpose of the visit.

During investigation, the Department interviewed staff, reviewed R1's file including but not limited to, admission agreement, list of medications, MAR, staff schedule, death report, and incident reports.

Allegation: Staff are not providing adequate care and supervision to the residents
Based on interview and records review, staff checked R1 at least every two hours as part of resident’s care plan, staff was also instructed to monitor R1 at least every hour during R1’s active dying process.

…Continue on LIC9099C…
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20211018110953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELDERS INN ON WEBSTER
FACILITY NUMBER: 015600526
VISIT DATE: 06/01/2022
NARRATIVE
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Allegation: Staff is sleeping in the common area

Based on interview, there is no staff or resident observed any staff sleeping in the common area.

Allegation: Staff are not properly trained to care for residents

Based on interview and records review, staff complete their training from an off-site building before starting at the facility. Facility used online system for all required staff training except for 16-hours hands on training which is being conducted at the facility.

Allegation: Staff do not follow medical orders as required

Based on interview and records review, Medical Administration Report (MAR) was completed, meaning the medication was given to R1, staff also documented medication refusal from R1. R1 was admitted into hospice care on 8/12/21 for end of life comfort care and life expectancy was less than six months. It was noted in her hospice records that R1’s family's wishes are for her to be comfortable at home with comfort measures only. They did not want any further aggressive treatment or any life sustaining procedures. On 9/12/2021, R1 was found on the floor, care staff conducted an assessment, reported the fall to Hospice agency and requested an assessment from a hospice nurse.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211018110953

FACILITY NAME:ELDERS INN ON WEBSTERFACILITY NUMBER:
015600526
ADMINISTRATOR:MARIE ANN LAGASCAFACILITY TYPE:
740
ADDRESS:1721 WEBSTER STREETTELEPHONE:
(510) 521-9200
CITY:ALAMEDASTATE: CAZIP CODE:
94501
CAPACITY:60CENSUS: 36DATE:
06/01/2022
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Stephen Zimmerman, AdministratorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
Neglect/Lack of Care and Supervision resulting in the death of resident
Staff did not seek timely medical attention for a resident
Staff is overcharging for services not received
INVESTIGATION FINDINGS:
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On 6/1/2022 at 11:15 AM, Licensing Program Analyst (LPA) L. Ibo conducted an unannounced complaint visit, met with administrator Stephen Zimmerman, gathered information and delivered investigation finding to administrator. LPA explained the purpose of the visit.

During investigation, the Department interviewed staff, reviewed R1's file including but not limited to, admission agreement, list of medications, MAR, staff schedule, death report, and incident reports.

…Continue on LIC9099C…
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20211018110953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: ELDERS INN ON WEBSTER
FACILITY NUMBER: 015600526
VISIT DATE: 06/01/2022
NARRATIVE
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R1 was admitted into hospice care on 8/12/21 for end of life comfort care, life expectancy was less than six months. It was noted in her hospice records that R1’s family's wishes are for her to be comfortable at home with comfort measures only. They did not want any further aggressive treatment or any life sustaining procedures. On 9/12/2021, staff found R1 on floor, R1 had history of falling and the facility developed a fall plan and facility was following it. Staff check vital sign and assessed R1, facility reported the incident to hospice agency and requested for nurse assessment. Hospice agency arrived at the facility and assessed R1. Based on interview and records review, hospice nurse assessed resident and appeared to be asleep and comfortable and did not see any indication of neglect. Hospice nurse stated when she arrived, a facility nurse and caregiver were present in R1’s room checking her vitals. R1 did not have any major injuries and she appeared comfortable.

Allegation: Staff is overcharging for services not received

Based on records review, signed admission agreement stated that rent will continue to be charged until all personal belongings, clothing, and furnishing have been removed. Based on records review, family emptied the apartment not until Sept. 16, 2021 which was a day after R1’s passing.

Based on information gathered, the allegations are unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20211018110953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELDERS INN ON WEBSTER
FACILITY NUMBER: 015600526
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2022
Section Cited
CCR
87211(a)(1)
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Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
This requirement is not met as evidence by:
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Licensee has agreed to review reporting requirements and submit self-certification to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not submitting incident report to CCLD which poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie IboTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6