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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200484
Report Date: 04/21/2022
Date Signed: 04/21/2022 06:19:01 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
06/21/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210621123307
FACILITY NAME:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 34DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Divine Ramirez, Assistant Executive DirectorTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Staff did not ensure a resident is taking their medications as prescribed
Staff did not provide appropriate resident documentation for emergency personnel
INVESTIGATION FINDINGS:
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On 4/21/2022 at 3:30PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPA met with Assistant Executive Director, Divine Ramirez.

During the course of investigation, LPA interviewed 6 staff. LPA also obtained and reviewed R1's file including: physician's report, care plan, emergency information, care notes, medication list, MAR (Medication Administration Record), doctor communication notes, and incident report.

It was noted on the MAR and care notes that R1 refused medications a few times in June of 2021. Interview with staff indicated that R1's PCP (Primary Care Physician) and family members were notified when R1 refused medications. Care notes revealed that there were discussions with R1's family regarding R1's refusal of medication and next steps to address the issue. Additionally, R1's PCP was notified via fax each time R1 refused medications. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
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 2
Control Number 15-AS-20210621123307
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: SUNOL CREEK MEMORY CARE
FACILITY NUMBER: 019200484
VISIT DATE: 04/21/2022
NARRATIVE
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Interview with staff revealed that an emergency packet is created for each resident in situations where resident would be sent out to the hospital. R1's emergency packet included picture ID, social security card, insurance cards, advance directives, physician's report, POLST, resident consent, and service plan. When R1 was sent to the hospital, EMTs were given an emergency packet. Staff stated that other documents such as MAR would be provided to EMTs if requests were made.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2