015601501-6-1-2022-15-AS-BFOG-CH4RLH-20220808130711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015601501
Report Date: 06/01/2022
Date Signed: 06/01/2022 04:01:31 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
07/10/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200710153037

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: 71	DATE:	06/01/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Diane Pederson/Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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-Neglect/lack of supervision: Resident (R1) sustained multiple falls resulting in injuries.

-Neglect/lack of supervision: Resident (R1) was not provided medical attention in timely manner.

-Neglect/lack of supervision: Staff failed to respond to resident’s (R1) pull cord in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Executive Director Diane Pederson, and informed the purpose of LPA’s visit.

During the course of the investigation, the Department conducted interviews with staff, resident’s responsible person (FM1) and medical provider. The Department obtained copies of R1’s medical records, Physician’s Reports, incident reports, facility notes, Appraisal/Needs and Services Plan, hospital discharge documents and/or Hospital After Visit Summaries, doctor's orders of medications, and Medication Administration Records for April 2020 and May 2020.

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

Unsubstantiated

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: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

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-20200710153037

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: 06/01/2022

NARRATIVE

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Page 2

Allegation: Resident (R1) sustained multiple falls resulting in injuries.
It was alleged that R1 fell on September 2019 outside in the facility garden; the drain cover was not properly covered and R1 tripped, broke her right shoulder, and was left for 2 hours. It was further alleged that R1 fell 4x in April 2020 and May 2020 resulting to broken ankle, toe and fingers.

The Department conducted interviews, obtained and reviewed R1’s Physician’s Reports, Appraisal/Needs and Services Plan, medical records, facility notes and incident reports. R1 fell in November 2019 when R1 was walking her dog in the back area. It could not be proven that R1 had tripped over an open drain cover. At that time, R1 had been appraised as being ambulatory without needing assistance. Progress notes indicated that staff immediately heard R1 and responded; R1 was immediately sent out to hospital and treated for an arm fracture. Facility reassessed R1 and determined that she needed additional supervision and care. The staff signed off daily for the tasks related to her increased care including additional safety checks. In January 2020, R1 experienced an unwitnessed fall in her room, with no injuries, bruising, or pain noted. The two other falls, with injury, were unwitnessed while R1 was in her room and on April 2020 when R1 attempted to use the bathroom on her own. Staff reported that R1 had been provided with additional room checks and reminders to call for assistance for bathroom transferring; documents obtained indicated staff were provided with this instruction. R1 had two more visits to the emergency department due to staff observing R1 with leg edema. The information is insufficient to establish that R1’s multiple falls were due to neglect or lack of supervision.

Allegation: Resident (R1) not provided medical attention in a timely manner.
The documents indicated the facility reported each incident and sought immediate medical treatment by having hospital evaluations. A review of R1’s incident reports and staff progress notes showed that facility staff had contacted paramedics and R1’s family to transport R1 to the hospital for an evaluation and treatment of injuries when R1 fell. Facility also sent R1 out to the hospital for treatment of leg edema. S1 reported during interview of personally responding to the fall in November 2019 and contacting 911 immediately after assessing R1, which was corroborated by documents obtained. The information is insufficient to establish that facility staff did not seem timely medical attention for R1.

,,,,,,continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20200710153037

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: 06/01/2022

NARRATIVE

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Page 3

Allegation: Staff do not respond to resident's pull cord in a timely manner.
Pull cord activations are answered by front desk and front desk staff will radio staff to respond to residents’ requests/calls. Seven staff (S1, S2. S3, S4, S5. S6 and S7) were interviewed who stated they are to respond immediately when pull cords are activated, and if unavailable, staff inform the front desk so that other staff can be requested to respond. The facility does not have a system that records when residents activate the pull cord, nor when staff respond. Therefore, it could not be determined whether R1 had called for assistance before attempting to use the shower or toilet, nor when staff responded to the pull cord being activated by R1.

Residents (R2, R3 and R4) were interviewed. R2 and R3 stated they seldom use their pull cords and staff usually respond immediately. R4 indicated he does not use pull cord and use his cell phone instead and staff respond immediately. The information was insufficient to determine that the facility staff had failed to respond to a call for assistance in a timely manner.

Based on all information obtained by the Department, the 3 allegations, “R1 sustained multiple falls resulting in injuries”, “R1 not provided medical attention in a timely manner”, and “Staff do not respond to resident's pull cord in a timely manner”, are closed as unsubstantiated. An unsubstantiated finding means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and copy of this report provided to Diane Pederson.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
07/10/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200710153037

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: 71	DATE:	06/01/2022
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Diane Pederson/Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility not properly administering medications to resident (R1)

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver findings for the above allegation. LPA met with Executive Director Diane Pederson.

During the course of the investigation, the Department conducted interviews with staff and resident’s (R1) responsible person (FM1). The Department obtained copies of R1’s medical records, Physician’s Reports, incident reports, facility notes, doctor's orders of medications and Medication Administration Records.

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

Unfounded

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: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20200710153037

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: 06/01/2022

NARRATIVE

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Page 2

Review of Medication Administration Record (MAR) showed R1 was generally compliant with taking her medications as directed. A review of the medication administration record for R1 indicated that staff had provided medications. S3 and S4 confirmed having signed their initials on the days and times that medication was provided or refused. The record indicated that one medication was occasionally refused by R1. S3 and S5 reported that R1’s physician was informed when the medication was refused. The information is insufficient to determine that the facility staff had failed to properly administer R1’s medications.

Based on all information obtained by the Department, the allegations is unfounded. A finding that a complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

Exit interview conducted and copy of this report provided to Diane Pederson.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5