015601222-11-21-2023-15-AS-KHOS-CYFMQV-20231212084919

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601222
Report Date: 11/21/2023
Date Signed: 11/21/2023 12:34:14 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
06/26/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230626092628

FACILITY NAME:	CARDINAL POINT AT MARINER SQUARE		FACILITY NUMBER:	015601222
ADMINISTRATOR:	GERALD VADNAIS		FACILITY TYPE:	741
ADDRESS:	2431 MARINER SQUARE DR		TELEPHONE:	(510) 337-1033
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94501
CAPACITY:	153	CENSUS: 105	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Avon Nguyen, Adimistrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility did not provide adequate supervision which resulted resident being abused while in care

INVESTIGATION FINDINGS:

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On 11/21/23 at 12:00 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to deliver findings on the above allegation. LPA met with Avon Nguyen, Adimistratorand explained the purpose of the visit.

Over the course of this investigation, the Department reviewed facility, medical, and collateral agency records, interviews of current staff, agency staff and facility clients. According to the Department’s review of Alameda Police Reports, facility notes, and statements from the Complainant, Client 1 (C1)’s power of attorney, other facility clients (Clients C2 and C3), and caregivers (Staff S1, S2, S3, S4, S5, and S6) C1 is currently on hospice and spends most, if not all, of her time in bed. C1 has private caregivers in addition to the facility staff to assist in her care 24/7.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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-20230626092628

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: CARDINAL POINT AT MARINER SQUARE	FACILITY NUMBER: 015601222
	VISIT DATE: 11/21/2023

NARRATIVE

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***report continues from LIC9099***

On 6/17/23 contracted care staff (S1) left C1’s room to get C1’s dinner. When S1 was returning to C1’s room she heard C1 yelling. Upon arrival S1 observed that C1 had a bump on her left forehead and a bruise on her left orbital. S1 called for back up and several facility staff arrived to assist. Staff applied an ice pack to C1’s forehead. C1 was not taken to the hospital per hospice order. S3 called Alameda Police Department (APD) who arrived at the facility and attempted to interview C1. C1 refused to be interviewed. On 7/27/2023 APD returned to the facility and interviewed C1. When asked about her injuries C1 stated that a “big and white” person did it but was unable to elaborate. APD confirmed through staff interviews that C1 does not have any “white” caregivers.

On 8/07/23 the department went to S1’s apartment to perform a follow-up interview. When asked how did S1 think C1 sustained her injuries S1 stated that since C1 was lying on her right side facing the bedrail when she left to get dinner C1 probably bumped her head against the bedrail. Staff now place a pillow between C1 and the bedrail and there have been no further injuries.

Interview with C2 who lives across the hall from C1 revealed that he often hears C1 “yelling and screaming” and that it is “a normal occurrence” for C1.

The Department has investigated the allegation that the facility did not provide adequate supervision which resulted in resident being abused while in care. We have found the allegation is unsubstantiated. 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 conducted and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

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