015601191-4-6-2023-15-AS-BFOG-CRW2QY-20230516173645

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601191
Report Date: 04/06/2023
Date Signed: 04/06/2023 12:14:53 PM

Unsubstantiated

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
09/28/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20220928173245

FACILITY NAME:	GRACE HOME CARE		FACILITY NUMBER:	015601191
ADMINISTRATOR:	DEL ROSARIO, GRACE		FACILITY TYPE:	740
ADDRESS:	17121 VIA ALAMITOS		TELEPHONE:	(510) 317-7548
CITY:	SAN LORENZO	STATE: CA	ZIP CODE:	94580
CAPACITY:	6	CENSUS: 5	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Marcelina Olisa, Caregiver		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident sustained a pressure injury while in care.

INVESTIGATION FINDINGS:

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On 04/06/2023 at 11:40 AM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Caregiver, Marcelina Olisa and disclosed the purpose of the visit and was granted entry into the facility. 5 residents and 2 staff were present in the facility during the delivery. The facility is a 4-bedroom, and 2 bathroom house. LPA spoke with Grace Del Rosario via phone call, Administrator gave permission to caregiver to sign report forms.

ALLEGATION: Resident sustained a pressure injury while in care
Investigation finding: UNSUBSTANTIATED

During the course of the investigation the Department interviewed 3 staff, 3 residents in care and obtained & reviewed the following documents: Facility & staff roster, incident reports, Physicians report, preplacement appraisal, after visit summary report, MAR (Medication Administration Record), and CSMDR (Centrally Stored
CONTINUE ON LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220928173245

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: GRACE HOME CARE	FACILITY NUMBER: 015601191
	VISIT DATE: 04/06/2023

NARRATIVE

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CONTINUE FROM LIC9099

Medication and Destruction Record). Interview with staff and record review revealed that S1 has been taking care of R1 starting on May 16, 2022, at this time S1 stated there was no issues with R1 skin for 3 weeks, S1 then noticed a red area, S1 took pictures and reported it to S3 along with photos. S3 instructed S1 to apply Mckesson skin protectant ointment with vitamin A&D over the counter ointment the red spot went away. R1 developed the red spot again and S1 under the direction of S3 applied the Mckesson skin protectant ointment with vitamin A&D again red spot was going away and R1 had an emergency and ended up in the hospital. The wound got worse and was treated by hospital, R1 returned to the facility with wound care orders. There is not enough evidence to prove or disprove that R1's wound developed into a pressure ulcer and was a result of neglect.

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

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

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