015601455-12-28-2021-15-AS-YFLS-CJ2LHR-20220907084647

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601455
Report Date: 12/28/2021
Date Signed: 12/28/2021 04:00:59 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
07/16/2020 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200716113133

FACILITY NAME:	REDWOOD ROAD CARE HOME		FACILITY NUMBER:	015601455
ADMINISTRATOR:	LIN, XIANG(DAVID)		FACILITY TYPE:	740
ADDRESS:	20112 REDWOOD ROAD		TELEPHONE:	(510) 703-8063
CITY:	CASTRO VALLEY	STATE: CA	ZIP CODE:	94546
CAPACITY:	14	CENSUS: 0	DATE:	12/28/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Xiang "David" Lin, Administrator		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1. Personal Rights - Resident sustained a pressure injury while in care.
2. Facility staff failed to meet resident's incontinence needs
3. Staff unable to communicate with resident due to language barrier.
4. Staff not fingerprint cleared
5. Facility has inadequate staff

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 12/28/2021 at 3:15 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Administrator Xiang "David" Lin and explained the purpsoe of the visit.

On 3/17/2021, Licensing Program Analyst (LPA) Luisa Fontanilla conducted a televisit and met with Administrator Xiang "David" Lin. The purpose of televisit is to deliver findings on the above allegations. LPA explained to Lin that this visit is being conducted via zoom in compliance with the telework directive by management.

****continuation on Lic 9099C****

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

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 6

Control Number 15-AS-20200716113133

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: REDWOOD ROAD CARE HOME	FACILITY NUMBER: 015601455
	VISIT DATE: 12/28/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

1. Personal Rights - Resident sustained a pressure injury while in care.
2. Facility staff failed to meet resident's incontinence needs
The Department has investigated the above allegations. Based on the Department's observations, interviews conducted, and records review, facility failed to provide adequate care to R1 resulting in a stage 4 pressure wound. R1 requires two person assist and would need assistance with all activities of daily living including repositioning. R1 was observed by home health with diapers frequently soiled and/or saturated with feces or urine. Administrator claims that R1 was non-compliant with repositioning.

However, Administrator acknowledged there was no documentation to support R1's non-compliance and facility failed to actively seek medical attention for R1 despite non-compliance. R1 was admitted to the hospital from 7/20/2020 to 7/24/2020 diagnosed with sacral decubitus ulcer stage IV, etc. and was later discharged to a skilled nursing facility.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

3. Staff unable to communicate with resident due to language barrier.
On 7/21/2020 and 8/6/2020, LPA contacted the facility and spoke with S3, LPA observed that during the conversations, S3 was having a hard time responding to LPA's questions in English. R1 confirmed that S3 has difficulty communicating in the English language.

4. Staff not fingerprint cleared
Based on LIS verification made by LPA L. Fontanilla and Lic 500 submitted by Administrator , S3 is not fingerprint cleared or associated to the facility. R1 confirmed with LPA that S3 works at the facility day and night, 7 days a week. A $500 civil penalty is being assessed for caregiver background clearance and will continue for $100 per day until corrected.

****continuation on Lic 9099C****

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 15-AS-20200716113133

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: REDWOOD ROAD CARE HOME	FACILITY NUMBER: 015601455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 12/29/2021 Section Cited CCR 87625(2)	1 2 3 4 5 6 7	*THIS IS AN AMENDED REPORT FROM VISIT ON 12/28/2021* 87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.	1 2 3 4 5 6 7	*THIS IS AN AMENDED REPORT FROM VISIT ON 12/28/2021* By POC date, Administrator will review Sec. 87625 Managed Incontinence with staff and submit self-certification of understanding to CCL by POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted by the Department, R1 was observed by home health staff frequently soiled and saturated with feces or urine, Home health staff described that R1 was so soaked that one could squeeze the undergarment and urine would come out which is an immediate health and safety risk to R1.	8 9 10 11 12 13 14
Request Denied Type A 03/18/2021 Section Cited CCR 1569.269(a)(6)	1 2 3 4 5 6 7	Enumerated rights; severability a) Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	R1 has moved out of the facility to recover in a skilled nursing facility. A Noncompliance Conference (NCC) was conducted on 8/25/2020 and Administrator was required to complete classes on observation of residents.LPA will need to verify the hours and classes completed.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on the Department's investigation, facility failed to provide sufficient care and supervision to R1 which resulted to R1 developing stage 4 pressure injury.R1 was hospitalized for treatment of sacral decubitus ulcer stage IV and was later discharged to a skilled nursing facility.	8 9 10 11 12 13 14	A $500 Civil Penalty is being assessed.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 15-AS-20200716113133

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: REDWOOD ROAD CARE HOME	FACILITY NUMBER: 015601455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 03/18/2021 Section Cited CCR 87411(g)(1)	1 2 3 4 5 6 7	Personnel Requirements - General Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or	1 2 3 4 5 6 7	By POC date, Administrator states that S3 will be removed from the facility immediately and will not be allowed to work until fingerprint cleared/associated to the facility. Civil penalty of $500 is assessed
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interview with R1, Lic 500 and LIS, S3 who is not fingerprint cleared and is not associated to the facility has been working at the facility which poses an immediate health and safety risk to clients under care	8 9 10 11 12 13 14
Request Denied Type B 03/19/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs............ This requirement is not met as evidenced by: Based on interviews conducted and records	1 2 3 4 5 6 7	A Non Compliance Conference (NCC) was conducted on 8/25/2020 and this concern has been addressed during NCC. Administrator was required to complete training hours. LPA will have to verify.
	8 9 10 11 12 13 14	reviewed, facility did not have sufficient staff to meet the needs of the residents. R1 needs two-person assist with transfers and needs repositioning every 2 hours to prevent pressure injury. Facility failed to reposition R1 as instructed due to insufficient staff which resulted to stage 4 pressure injury.	8 9 10 11 12 13 14

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 15-AS-20200716113133

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: REDWOOD ROAD CARE HOME	FACILITY NUMBER: 015601455
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 03/19/2021 Section Cited CCR 87411(d)(3)	1 2 3 4 5 6 7	Personnel Requirements - General All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents.	1 2 3 4 5 6 7	By POC date, Administrator will conduct staff training on how to communicate with residents in regards to resident care and supervision, how to communicate with 911 operators/paramedics, doctors and others related to care of residents. Proof will be sent to LPA by POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and LPA conversations with S3, LPA observed S3 was having difficulty communicating in basic English conversations. R1 confirmed with LPA that S3 does have difficulty speaking and understanding English.	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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 15-AS-20200716113133

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: REDWOOD ROAD CARE HOME	FACILITY NUMBER: 015601455
	VISIT DATE: 12/28/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

5. Facility has inadequate staff
A review of Lic 500 and LIS show that there are only 2 staff working/associated at the facility, Administrator and S2. Administrator states that he and his wife are the only staff working 24/7. Based on interview with R1, facility does not have sufficient staff to care for the residents. R1 states that Administrator does come to the facility to help out a little bit but leaves afterwards. R1 requires two - person assist with transfers and needs full assistance with all activities of daily living including repositioning every two hours. R1 states that S3 is the only staff who works 24/7. R1 states that R2 is also present but has to care for her 2 children at home.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099 D.

Exit interview conducted and a copy of Appeal Rights sent to Administrator via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 6 of 6