015601501-5-14-2025-15-AS-KHOS-DH2TRR-20250526145800

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601501
Report Date: 05/14/2025
Date Signed: 05/14/2025 02:28:10 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
02/03/2022 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20220203093410

FACILITY NAME:	LANDMARK VILLA		FACILITY NUMBER:	015601501
ADMINISTRATOR:	DIANE PEDERSON		FACILITY TYPE:	740
ADDRESS:	21000 MISSION BLVD.		TELEPHONE:	(510) 276-2872
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	140	CENSUS: 72	DATE:	05/14/2025
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Diane Pederson/Executive Director		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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-Resident (R1) sustained pressure injuries while in care.
-Resident's diapering needs are not being met.
-Resident's hygiene needs are not being met.
-Staff does not assist resident when requested.
-Staff does not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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On this day, May 14, 2025, at 11:35 am, Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director (ED) Diane Pederson, and informed the purpose of visit.

During the course of investigation, LPA reviewed residents’ records and obtained copies of including but not limited to the following residents’ documents: LIC601 Identification and Emergency Information; LIC602 Physician's Report; Pre-admission Appraisal; Reappraisal; facility notes; hospital After Visit Summary. LPA obtained copies of staff schedule, resident roster, and obtained records from Home Health agency that attended to R1 from 2021 to 2022.

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

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

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 5

Control Number 15-AS-20220203093410

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: LANDMARK VILLA	FACILITY NUMBER: 015601501
	VISIT DATE: 05/14/2025

NARRATIVE

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Page 2

LPA conducted inspection with ED on 2/07/22. LPA interviewed the following: staff (ED, S1, S2, S4, S5, S6) on 2/07/22, 9/28/23, 9/05/24, 9/13/24 and 4/30/25; R1’s family member (FM1) on 9/13/24; residents (R2, R3, R4, R6, R7, R8) on 2/07/22, 9/28/23 and 4/30/25. LPA tried to reach staff (S3) and home health nurse (HH1), but they did not return LPA’s calls.

Allegation: Resident (R1) sustained pressure injuries while in care.

S1 stated she does not remember if R1 had pressure injury but thinks R1 had some redness which is usual when one is staying long on the chair and R1 was attended by home health. S2 stated she was not assigned to R1 but observed caregivers attended to R1. S4 stated she does not remember R1 because residents come and go but if she observes skin issue, she reports to the med-tech and she repositions resident every 2 hours. S5 and S6 stated R1 had pressure injury. S6 also stated that that was also the reason R1 was visited by home health which was also stated by FM1. S5 and S6 stated R1 was a difficult resident. S5 further stated when R1 was repositioned, R1 returned to her original position. R1 was provided wedge; however, R1 asked the staff remove it.

Review of home health records showed R1 was certified and re-certified for home health care from 2021 to 2022 and at some point, during these periods, R1 was visited by home health due to pressure injury. On 3/08/22 document indicated R1 was discharged from Home Health. It was noted on the document that R1 has no unhealed or stage 2 or higher pressure injury and had no stasis ulcer.

Based on interviews and records review, and LPA unable to obtain information from R1, S3 and HH1, the allegation is unsubstantiated.

Allegation: Resident's diapering needs are not being met.

It was reported that when HH1 asked R1 to stand up so HH1 can see R1’s buttock wound, R1 said, “Let me first pee in my diaper” and when R1 was done, HH1 helped remove the diaper and amount of urine was weighing 2-3x of urine episode and that was causing the stage 2 pressure injury in the buttock. ..............................continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20220203093410

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: LANDMARK VILLA	FACILITY NUMBER: 015601501
	VISIT DATE: 05/14/2025

NARRATIVE

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Page 3

FM1 stated once or twice R1 called her and told her she was not changed but FM1 said it was something she was not aware of. Although FM1 stated that she run a couple of times when she visited and saw used diaper in a plastic bag in R1's bed, she never observed R1 soaked in urine nor not changed.

S1 stated when R1 does not come down to the dining room, S1 goes to R1's room to give R1 medications and S1 observed caregiver changing R1's diaper. There were times when R1 will call for assistance and S1 hears the front desk calling for caregiver to attend to R1. S2 stated she never visually observed R1 soaked in urine or soiled and not being attended. S2 also stated she saw caregivers come and go to R1's room to attend to R1. S4 stated she changes residents’ diapers 3x during her shift and as needed. S5 stated residents who need assistance in changing diaper are changed regularly and as needed. S6 stated she changed residents' diapers every 2 to 3 hours and more often if resident is a frequent wetter. S6 further stated that R1 was a frequent wetter and a lot of time, R1 refused to be changed.

Six of the residents interviewed stated the staff assist them when they need help. One of this 6 residents has been living in the facility for 8 years and stated that she needs assistance in changing diaper and staff change her 4 to 5 times and as needed. This resident further stated she never had rashes, UTI and/or pressure injury.

Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated.

Allegation: Resident's hygiene needs are not being met.

It was reported that HH1 observed feces between R1’s buttock and some part at R1’s back which showed that the feces had been sitting there and that when staff wiped off, R1 was not cleaned entirely.

.......continued on 9099C (page 4)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20220203093410

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: LANDMARK VILLA	FACILITY NUMBER: 015601501
	VISIT DATE: 05/14/2025

NARRATIVE

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FM1 stated R1 complained about the water being cold and would not want to take a bath, but FM1 tested the water and the temperature was okay. FM1 also stated that when FM1 started coming to the facility, R1 started taking a bath.

All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment.

Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated.

Allegation: Staff does not assist resident when requested.

All 6 residents interviewed stated the staff assist them when they need help. When LPA conducted inspection during the 10-day visit, when LPA and the ED entered one of the residents’ apartment, LPA observed a caregiver present and assisting the resident in that apartment.

Based on information gathered, and LPA unable to obtain information from HH1 and R1, the allegation is unsubstantiated.

Allegation: Staff does not treat resident with dignity and respect.

It was reported that HH1 observed the staff being disrespectful to R1.

All staff interviewed denied being abusive to any residents. They stated they never observed other staff not treating residents with dignity and respect.

..............continued on 9099C (page 5)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20220203093410

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: LANDMARK VILLA	FACILITY NUMBER: 015601501
	VISIT DATE: 05/14/2025

NARRATIVE

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FM1 stated she never heard any staff being disrespectful to R1 or other residents. All 6 residents interviewed stated staff were never abusive to them and other residents.

LPA reviewed Home Health records and documentation and didn’t observe any notes indicating HH1 observed abuse by facility staff. Based on information gathered, and LPA unable to obtain information from HH1, S3 and R1, the allegation is unsubstantiated.

Based on interviews, observations and records review, there’s not a preponderance of evidence standard to prove that violations occurred, therefore, the 5 allegations are closed as unsubstantiated.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025

LIC9099 (FAS) - (06/04)

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