015601501-11-12-2021-15-AS-KHOS-C9BPA2-20211202100801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601501
Report Date: 10/13/2021
Date Signed: 11/12/2021 04:07:53 PM

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
09/26/2019 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20190926095603

FACILITY NAME:	LANDMARK VILLA		FACILITY NUMBER:	015601501
ADMINISTRATOR:	PEDERSON, DIANE		FACILITY TYPE:	740
ADDRESS:	21000 MISSION BLVD.		TELEPHONE:	(510) 276-2872
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	140	CENSUS: 75	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Executive Director Diane Pederson.		TIME COMPLETED:	06:15 PM

ALLEGATION(S):

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Lack of care or supervision resulted in a resident's (R1) AWOL.

Lack of care or supervision resulted in a resident's (R1) fall and serious bodily injuries

INVESTIGATION FINDINGS:

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THIS IS AN AMENDMENT OF LIC9099 COMPLAINT INVESTIGATION REPORT DATED 10/13/2021.

Licensing Program Analyst (LPA) Delmundo arrived at the facility unannounced to deliver the findings on the above allegations. LPA met with Executive Director Diane Pederson. and informed the purpose of visit.

It was alleged that resident (R1) who has history of dementia has been found down in the community. A bystander called 9-1-1 due to R1 has visible injuries.

.
..continued on 9099C

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: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20190926095603

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: 10/13/2021

NARRATIVE

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During the course of investigation, LPA obtained copies of resident roster, staff schedule and reviewed R1’s documents including but not limited to Physician’s Report, hospital discharge documents, appraisal, hospice care documents, Facility Service Notes, lists of medications, Admission Agreement and Power of Attorney. LPA also obtained copies of police report and medical records, and conducted interviews,

Two of the staff interviewed indicated R1 has wandering behavior and was able to leave the facility unnoticed. Staff indicated they came to know R1 was missing when the caregiver asked where R1 was. Staff drove around and searched but was unsuccessful. They called law enforcement and reported R1 was missing. R1 was found by bystander who called 9-1-1. Facility records and medical records showed R1 has dementia. Medical records further revealed R1 sustained right zygomatic arch, right orbital wall, right maxillary wall, and left maxillary wall fractures, and right middle finger avulsion fracture resulting from fall.

Based on the information gathered, the allegations are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). A $500.00 civil penalty is assessed. Failure to submit proof of correction by plan of correction due date may result in additional civil penalty.

Deficiency, plan and proof of correction and civil penalty were discussed with Diane Pederson,.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment, 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: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20190926095603

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/14/2021 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (b)(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials. -This requirement is not met as evidenced by:	1 2 3 4 5 6 7	R1 is no longer in the facility. Executive Director to do the following and submit proof by 10/14/2021: 1. Have auditory signals installed on entrance and exit doors, and ensure they are functional at all times and submit pictures.
	8 9 10 11 12 13 14	-Based on interviews and records review, the licensee did not comply with the section above for retaining R1 with dementia. R1 was able to AWOL which posed immediate safety risk to person in care.	8 9 10 11 12 13 14	2. In-service all staff and submit copy of in-service training with attendees signatures.
Type A 10/14/2021 Section Cited CCR 87468.2	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a).... elderly shall have all of the following personal rights: (4) 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	Executive Director to conduct in-service training and submit proof by POC date. A $500.00 civil penalty is assessed.
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: -Based on interviews and records review, the licensee did not comply with the section above. R1was able to AWOL unnoticed. R1 fell resulting to sustaining injuries. These posed immediate safety and personal rights and safety risks to person in care. Civil penalty is assessed.	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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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