<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200305
Report Date: 09/12/2024
Date Signed: 09/12/2024 06:50:49 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
01/07/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220107090126
FACILITY NAME:REDWOOD HOME AT NILES GROVEFACILITY NUMBER:
019200305
ADMINISTRATOR:EDITH SARMIENTOFACILITY TYPE:
735
ADDRESS:35537 NILES BLVDTELEPHONE:
(510) 818-0720
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 6DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Edith Sarmiento/Administrator TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility retained resident (R1) beyond the limitation of license.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 4:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with staff, Myra Quevedo and Rodamen Arreola. Edith Sarmiento, administrator (ADM), arrived at 5:30 pm.

It was alleged that R1 can not reposition of his own.

During the course of investigation, LPA obtained copies of staff schedule and LIC500 Personnel Report, and copies of the following resident's (R1) documents: LIC602 Physician's Report; LIC601 Identification and Emergency Information; Individual Program Plan; Reposition and Change Logs.


.....continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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-20220107090126
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 HOME AT NILES GROVE
FACILITY NUMBER: 019200305
VISIT DATE: 09/12/2024
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
On 1/13/22, 9/10/24, 9/11/24 and 9/12/24, LPA interviewed 5 staff, previous executive director (PED), administrator (ADM) and R1. PED stated R1 can not reposition on his when in bed. ADM stated R1 can not reposition when in bed as well as when R1 is on his wheelchair. ADM also stated that R1 can only press the button on his wheelchair to have his leg elevated. The 5 staff stated R1 is being repositioned which is confirmed by LPA from the document obtained. R1 stated he can not reposition on his own.

Based on interviews and records review, and facility not licensed for bedridden nor have bedridden fire clearance at the time complaint was received, the preponderance of evidence is met, therefore, the allegation of facility retained resident (R1) beyond the limitation of license is closed as substantiated.

Deficiency is cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 civil penalty is assessed for section 80020(a).

Deficiency and civil penalty were discussed with ADM.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty Assessment and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220107090126
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 HOME AT NILES GROVE
FACILITY NUMBER: 019200305
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2024
Section Cited
CCR
80020(a)
1
2
3
4
5
6
7
80020 Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

-This requirement is not met as evidenced by:
1
2
3
4
5
6
7
A $500.00 civil penatly is assessed.

Corrected.
Facility applied for bedridden. Fire clearance and license for bedridden has been granted.

8
9
10
11
12
13
14
-Based on interviews and records review, the licensee did not comply with the section above for not having bedridden fire clearance and retained R1.

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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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
01/07/2022 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20220107090126

FACILITY NAME:REDWOOD HOME AT NILES GROVEFACILITY NUMBER:
019200305
ADMINISTRATOR:EDITH SARMIENTOFACILITY TYPE:
735
ADDRESS:35537 NILES BLVDTELEPHONE:
(510) 818-0720
CITY:FREMONTSTATE: CAZIP CODE:
94536
CAPACITY:6CENSUS: 6DATE:
09/12/2024
UNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Edith Sarmiento/Administrator TIME COMPLETED:
07:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Facility retained resident (R1) who is unable to care for own restricted health condition.

-Resident (R1) sustained pressure injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
At 4:35 pm, Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with staff, Myra Quevedo and Rodamen Arreola. Edith Sarmiento, administrator (ADM), arrived at 5:30 pm.

During the course of investigation, LPA obtained copies of staff schedule and LIC500 Personnel Report, and copies of the following resident's (R1) documents: LIC602 Physician's Report; LIC601 Identification and Emergency Information; Individual Program Plan; Reposition and Change Logs. LIC625 Appraisal/Needs and Services Plan; hospital discharge documents; incident reports; list of medical appointments; Home Health Visit Records; Flushing Records; staff training records


....continued on 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
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-20220107090126
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 HOME AT NILES GROVE
FACILITY NUMBER: 019200305
VISIT DATE: 09/12/2024
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
Allegation: Facility retained resident who is unable to care for own restricted health condition.
It was alleged that R1 has catheter and that R1 has 'physical limitations'.

On 1/13/22, 9/10/24, 9/11/24 and 9/12/24, LPA interviewed 5 staff, previous executive director (PED) and ADM who all confirmed R1 had catheter when R1 was discharged from hospital on 12/2021. Due to R1's medical condition, R1 can not physically care for own catheter needs; however, all staff interviewed stated R1 was followed by home health nurse who trained the staff in emptying/draining the catheter bag. Review of documents confirmed the staff's statements.

Allegation: Resident (R1) sustained pressure injuries while in care.
Review of medical records showed R1 was sent from hospital on 12/14/21 to Skilled Nursing Facility (SNF) on 12/23/21. SNF records showed R1 had pressure injuries.

LPA interviewed ADM, PED and R1's family member (FM) on 1/13/22 and 10/24/22. ADM and PED stated R1 did not developed pressure injuries at the facility which was confirmed by R1's family member (FM). FM stated R1 stayed at the hospital for long period where he developed pressure injury. R1 never had pressure injury when R1 was at the facility.

Based on information obtained, both allegations are closed as unsubstantiated. A finding that the complaint is unsubstantiated 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.

No deficiency cited.

Exit interview conducted and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5