015601429-2-2-2023-15-AS-YFLS-CP2MAS-20230214082648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601429
Report Date: 02/02/2023
Date Signed: 02/02/2023 03:03:38 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-20220328170059

FACILITY NAME:	RAKSHA 4 CARE HOME		FACILITY NUMBER:	015601429
ADMINISTRATOR:	BHUTANI, BHUMI		FACILITY TYPE:	740
ADDRESS:	616 STANNAGE AVENUE		TELEPHONE:	(510) 912-6244
CITY:	ALBANY	STATE: CA	ZIP CODE:	94706
CAPACITY:	6	CENSUS: 6	DATE:	02/02/2023
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Nalini Bhutani, Administrator.		TIME COMPLETED:	03:30 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 10:00 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 11 deaths occurred at the facility from the year 2018 to 2023. LPA reviewed six (6) of eleven (11) Death Reports and one (1) Unusual Incident Report (UIR) for low blood pressure dated 12/27/18. Five (5) Residents passed away due to natural causes, terminal transitioning, cerebrovascular disease, renal disease, and Alzheimer’s; all residents received hospice services. One (1) Resident went for routine blood transfusion on 12/19/22; passed away at Oakland -Kaiser Permanente.
Continued on LIC9099C…

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 4

Control Number 15-AS-20220328170059

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 4 CARE HOME	FACILITY NUMBER: 015601429
	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) of seven (7) Staff (S1, S2, S5, S7), and confirmed they did not observe any bruising or pressure injuries on Residents (R1, R2, R4, R5) while in care at the facility. R3’s Physician’s Report dated 05/14/21 documented a history of skin condition – breakdown. R3 was admitted to the facility 02/18/2018, updated the admission agreement on 09/20/21 and still resides at the facility. Per S1, R3 has a rash condition which cream is prescribed and applied.
On 03/29/22, LPA observed two (2) Residents in the dining room eating dinner, S7 was preparing food for the Residents. S2 stated that S7 who was preparing food liked to cook and was also a good baker. 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 ground meat, chopped lettuce, onions, tomatoes, juice and water. Interview with W1, W1 stated that R1’s meals are fine and R1 receives ensure as a supplement. Physician’s Report dated 02/19/22 notes R1 is able to feed himself/herself and was admitted to the facility while on Hospice 10/16/21
An Interview with Witness #1 (W1) and record reviews revealed that R1 is non-ambulatory (paralysis), diagnosed with Dementia, and currently has a toe fungal infection with a 6-week medication regimen. W1 states the medication is being applied as prescribed, R1 does not like to be in bed all day, the facility assists with R1’s wheelchair and there aren’t any pressure sores. R2 and R4 do not have any mobile impairments at this time.

continued on LIC 9099C...

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 4

Control Number 15-AS-20220328170059

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 4 CARE HOME	FACILITY NUMBER: 015601429
	VISIT DATE: 02/02/2023

NARRATIVE

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...continued from LIC 9099C

Pest Control inspections, records and receipts revealed that the facility has had a proactive treatment plan in place with Terminix sincm 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)

Page: 4 of 4

Control Number 15-AS-20220328170059

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 4 CARE HOME	FACILITY NUMBER: 015601429
	VISIT DATE: 02/02/2023

NARRATIVE

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...continued fron LIC 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 reports did not have any 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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