015601285-2-2-2023-15-AS-YFLS-CP2MA2-20230214082537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601285
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:40:41 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
03/28/2022 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220328163633

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:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Nalini Bhutani, Co-Administrator.		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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Questionable death
Residents have developed pressure injuries while in care
Residents are not being provided a sufficient quantity of food
Residents are not being provided a sufficient quality of food.
Residents are not being rotated while in care
Facility has pests

INVESTIGATION FINDINGS:

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On 02/02/23 at 11:40 AM, Licensing Program Analyst (LPA) L. Holmes conducted an unannounced visit to deliver the findings for the above allegations. LPA explained the purpose of the visit and met with Nalini Bhutani, Administrator.

Allegation: Questionable death
Investigation Finding: UNSUBSTANTIATED
LPA confirmed with Staff #1 (S1) that a total of 20 deaths occurred at the facility from the year 2018 to 2022. LPA reviewed 14 of 20 Death Reports. Fourteen (14) Residents passed away due to natural causes, cancer, atherosclerosis, cerebrovascular disease, renal disease, COPD, and Alzheimer’s; all Residents received hospice services. One (1) Unusual Incident Report (UIR) for stroke symptoms dated 02/25/19.

Continued LIC 9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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 3

Control Number 15-AS-20220328163633

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: 02/02/2023

NARRATIVE

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…continued from LIC9099
Allegations:
Residents have developed pressure injuries while in care
Residents are not being provided a sufficient quantity of food
Residents are not being provided a sufficient quality of food.
Residents are not being rotated while in care
Facility has pests
Investigation Findings: UNSUBSTANTIATED

LPA interviewed four (4) Staff (S1, S2, S5, S7) of seven (7) and confirmed they did not observe any bruising or pressure injuries on Residents (R1, R2, R3, R4) while in care at the facility. R3’s Physician’s Report dated 05/14/21 documents a history of skin condition – breakdown. Per S1 and records, there weren't any physician's orders for R3's dry skin condition from date of admission 03/21/22 to discharge date of 10/23/22. Care staff would apply Aveeno lotion to obvious signs of dry skin as prevention and to aide R3's dry skin.
On 03/29/22, LPA observed two (2) Residents in the dining room eating dinner; S8 was preparing the food for the residents. One (1) Resident was watching television. S2 stated that S8 was a good cook. S2 not only shopped and purchased food/goods for the facilities, but also for the Staff to take home in order to cut down on the number of trips to the store and the potential spread of COVID-19. On 01/04/23, S1 provided three (3) monthly sample menu’s that appeared to be balanced meals for breakfast, lunch, two (2) snacks, dinner and desert consisting of a variety of daily nutrients. LPA observed what appeared to be a soup/stew being served, a dinner roll, juice and coffee.
Interviews with Witnesses (W1, W4) and record reviews revealed that R1 passed away 10/28/22, was diagnosed with Dementia, and that the facility aided R1 with research treatment and overseeing the donation of R1’s remains to science. W4 stated R1 is a fall risk, has had falls multiple times but is very independent. W4 feels like R4 is safe and both S1 and S2 have been a great help. W4 has been satisfied with the level of care since R4 moved into the facility in 2019. R5’s Physician’s Report dated 04/01/21 revealed R5 as having sundowning syndrome; R5 likes to sleep during the day and was noted having redness on his/her back; there were no additional orders. S1 stated that R5 likes to sleep all of the time, doesn't like to shower and shave often. R5 and R6 do not have any mobile impairments at this time, R1 was not a fall risk and health declined fairly quickly.

continued on LIC9099C...

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220328163633

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: 02/02/2023

NARRATIVE

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...continued from 9099C

Pest Control inspections, records and receipts revealed that the facility has had a proactive treatment plan in place with Terminix since 10/03/17. The quarterly report for 01/11/22 targeted ants, and on 04/12/22 there were no further recommendations or concerns.
Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited, exit Interview conducted and a copy of this report provided to Administrator, Nalini Bhutani.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC9099 (FAS) - (06/04)

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