019200144-12-8-2022-15-AS-BFOG-CMX3RM-20230109172858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200144
Report Date: 12/08/2022
Date Signed: 12/08/2022 02:23:51 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
02/17/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220217150813

FACILITY NAME:	MAKANA HOUSE, THE		FACILITY NUMBER:	019200144
ADMINISTRATOR:	VENERANDO GANO		FACILITY TYPE:	735
ADDRESS:	32219 TERI COURT		TELEPHONE:	(510) 441-1816
CITY:	UNION CITY	STATE: CA	ZIP CODE:	94587
CAPACITY:	4	CENSUS: 3	DATE:	12/08/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Melva Taclay, Staff Venerando Gano, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained a fall while in care
Resident was denied access to emergency personnel
Staff did not address a resident’s change in medical condition
Facility failed to obtain timely medical care for resident
Staff unable to provide personal information of a resident to the hospital

INVESTIGATION FINDINGS:

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On 12/08/22 at 1:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit, met with staff (S1) and spoke with administrator on the phone who authorized S1 to act on his behalf and sign the reports. LPA explained the purpose of the visit with S1 & administrator and delivered the investigation findings.

Allegation: Resident sustained a fall while in care
Investigation Finding: UNSUBSTANTIATED
Based on interviews and review of records, it was found that R1 had an unwitnessed fall on 1/24/22 at approximately 10:00 am. S1 stated having heard R1 yell out and responded. S1 stated that R1 stated that she was “ok” and refused to be taken to the hospital. S1 stated that R1 was later in the day again offered an opportunity to be taken to the hospital but declined. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

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-20220217150813

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: MAKANA HOUSE, THE	FACILITY NUMBER: 019200144
	VISIT DATE: 12/08/2022

NARRATIVE

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Allegation: Resident sustained a fall while in care
Investigation Finding: UNSUBSTANTIATED
R1 passed away on 1/26/22 and review of the hospital records indicate that during the external examination, there was no evidence of injuries pertaining to a fall with no fractures or disassociations, and no epidural or subdural hemorrhage. Manner of death was deemed natural and unrelated to the fall of 1/24/22. Review of R1s file indicate that R1 was not a fall risk. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation occurred. Therefore, the allegation is Unsubstantiated.

Allegation: Resident was denied access to emergency personnel
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) had an unwitnessed fall at the facility on 01/24/22, with no information emerging that there had been an injury. Staff stated they offered to take R1 to the emergency room but she refused to go. On 1/26/22, R1 awoke at approximately 8:00 am. When staff went to R1s room to notify her that breakfast was ready, R1 informed staff of feeling dizzy and nauseous, and declined to eat. Staff contacted Administrator who conducted a video tele-visit with R1. At approximately 10:00 am, staff again called Administrator, who while speaking with R1, observed R1 lose consciousness. Paramedics were contacted at 10:23 and arrived at facility at 10:27 am. R1 expired while in transport to hospital. The Death Certificate lists the cause as natural, and unrelated to the fall that took place on 1/24/22. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Continued on next page, LIC 9099-C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220217150813

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: MAKANA HOUSE, THE	FACILITY NUMBER: 019200144
	VISIT DATE: 12/08/2022

NARRATIVE

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Allegation: Staff did not address a resident’s change in medical condition
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, staff stated resident (R1) had an unwitnessed fall, was evaluated, and refused to go to the hospital on 01/24/22. On 01/26/22, R1 reported to staff that she was feeling dizzy and nauseous. Staff contacted administrator who performed a video call with R1 to address her condition. Shortly thereafter, staff again contacted Administrator as they continued to observe R1 to be experiencing nausea; while on the second video call with Administrator, R1 lost consciousness, and the paramedics were contacted. The information obtained indicates that staff observed and addressed R1s condition during the incidents of 1/24/22 and 1/26/22. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Facility failed to obtain timely medical care for resident
Investigation Finding: UNSUBSTANTIATED
Based on interviews and records review, R1 had an unwitnessed fall on 1/24/22 and refused to be taken to the hospital. On 1/26/22, R1 informed staff of feeling dizzy and nauseous. The Administrator was contacted and a video call between the Administrator and R1 was conducted. Shortly following that, staff again contacted Administrator as R1 continued to experience nausea. While conducting a second video call, R1 lost consciousness and 911 was immediately contacted. Although the allegation may have happened or is valid, there is insufficient evidence to prove that the allegation. Therefore, the allegation is Unsubstantiated.

Allegation: Staff unable to provide personal information of a resident to the hospital
Investigation Finding: UNSUBSTANTIATED
Review of R1s file indicated that R1 had a case manager and acted as her own responsible party. A family member was listed as the nearest relative. The facility stated that the paramedics did not ask for this information, and that the hospital made no contact with the home. No contradictory information emerged that would disprove the facility staffs’ assertion. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the violation did occur. Therefore, the allegation is Unsubstantiated.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022

LIC9099 (FAS) - (06/04)

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