015601285-10-21-2022-15-AS-BFOG-CMX3PT-20230109172600

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601285
Report Date: 10/21/2022
Date Signed: 10/21/2022 05:28:42 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
12/03/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20211203145000

FACILITY NAME:	RAKSHA 13 CARE HOME		FACILITY NUMBER:	015601285
ADMINISTRATOR:	BHUTANI, SHALINI		FACILITY TYPE:	740
ADDRESS:	906 CORNELL AVENUE		TELEPHONE:	(510) 526-2533
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	13	CENSUS: 11	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	04:20 PM
MET WITH:	Nalini Bhutani/Co-administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Resident (R1) sustained opioid overdose while in care resulting in hospitalization.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Alicia Delmundo and Lori Alexander arrived unannounced to deliver the findings for the above allegation. LPAs met with staff, Sumitra Khadka. LPA Delmundo spoke with Nalini Bhutani, co-administrator, over the phone and informed the purpose of visit. Co-administrator arrived after about 25 minutes.

It was alleged that on the morning of 11/30/2021, staff was unable to awaken resident (R1). Staff called 9-1-1, and R1 was admitted into the hospital. A toxicology report was generated for R1 which reported a narcotic/opioid overdose.

.......continued on 9099C (page 2)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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 4

Control Number 15-AS-20211203145000

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: RAKSHA 13 CARE HOME	FACILITY NUMBER: 015601285
	VISIT DATE: 10/21/2022

NARRATIVE

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Page 2

During the course of investigation, the Department obtained copies of R1’s records including but not limited to medical records, list of medications, LIC602A Physician’s Report, LIC601 Identification and Emergency Information, Medication Administration Records, Incident Report, Fire Department Incident Report/9-1-1 call. The Department reviewed R1’s medications list, checked medications, and conducted interviews.
On 11/30/2021, at approximately 0915 hours, facility staff called 9-1-1 to report that resident (R1) was unresponsive. The fire department arrived at 0919 hours and found R1 unresponsive with pinpoint pupils and shallow respirations. Due to the signs and symptoms, paramedics believed R1 was suffering from a possible opioid overdose. Staff denied R1 was on any narcotics but paramedics administered Narcan anyway. R1 had a positive response to the Narcan and was transferred to hospital. While at the hospital, the Emergency Department staff administered two separate urine tests, and both came back positive for opioid. R1 was discharged from the hospital on 12/05/2021 with diagnosis of opioid overdose.

Staff (S1, S2 and S3) were interviewed. Staff denied providing R1 medication on 11/30/2021 and denied giving R1 wrong medication. Facility staff were unable to provide an explanation on how R1 had the opioid on R1’s system, stating someone may have given the medication while R1 sat outside or that it was provided by a family member two days prior. Family members (FM1 and FM2) were interviewed. FM1 was aware that FM3 visited on weekend prior to the incident and does not think the overdose will take effect two days after if FM3 has given something to R1. FM2 feels that the staff are the only people that have access to R1 aside from R1’s family. FM2 is confident that the siblings did not provide the medication to R1.

.......continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20211203145000

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: RAKSHA 13 CARE HOME	FACILITY NUMBER: 015601285
	VISIT DATE: 10/21/2022

NARRATIVE

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Page 3

Residents (R2. R3 and R4) were interviewed. One of these residents, R2, indicated running into a few issues on medications. R2 stated staff have given R2 medications in a cup with name of other resident in the cup. R2 also indicated that some staff leave the medication room open and unattended, and some staff make sure the medication room is closed.

During visits to the facility, the Department found the medication room door open and unattended on multiple occasions. The Department attempted to obtain video camera footage from the incident which Shalini Bhutani, administrator, reported was "accidentally deleted."

Based on all information obtained during the course of investigation, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D, Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty.

Deficiency and plan and proof of correction were discussed with Nalini Bhutani.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20211203145000

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: RAKSHA 13 CARE HOME	FACILITY NUMBER: 015601285
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/22/2022 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to conduct in-service training and submit copy of training topic with attendees signatures by 10/22/2022.
	8 9 10 11 12 13 14	-Based on records review, interviews and observation, the licensee did not comply with the section above for R1 sustaining opioid overdose which posed immediate health risk to person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4