019200487-8-22-2022-15-AS-BFOG-CLUTBD-20221206133457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200487
Report Date: 08/22/2022
Date Signed: 08/22/2022 11:39:01 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
02/25/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220225085646

FACILITY NAME:	CNS COURTYARD #146		FACILITY NUMBER:	019200487
ADMINISTRATOR:	STACEY MAGDEFRAU		FACILITY TYPE:	735
ADDRESS:	1465 65TH STREET, #146		TELEPHONE:	(925) 719-5580
CITY:	EMERYVILLE	STATE: CA	ZIP CODE:	94608
CAPACITY:	2	CENSUS: 1	DATE:	08/22/2022
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Stacey Magdefrau, Administrator		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Personal Rights-Resident sustained a fracture while in care
Personal Rights-Staff are not meeting resident's dietary needs
Personal Rights-Staff are not providing adequate laundry service for resident

INVESTIGATION FINDINGS:

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On 8/22/22 at 11:10 am, Licensing Program Analysts (LPAs) C. Lin and L. Fici conducted an unannounced subsequent complaint investigation regarding the above allegations and delivered investigation findings. LPAs explained the purpose of the visit with Administrator.

Allegation: Personal Right - Resident sustained a fracture while in care – Unsubstantiated
The Department has investigated this allegation and per records reviews and interviews, found that the resident sustained the fall while at a third-party physical therapist (PT) office on 7/9/2019. While during interview, the RP stated that the resident fell the day before, however, medical records do not indicate that the resident fell before or after the fall at the PT office; no other documentation was found to indicate any other falls, and the resident was again evaluated by the MD on 7/25/19 and 7/30/19 with no other injury discussed other than the one sustained at the PT office. Facility progress notes indicate that after the fall at the PT office, additional checks on the resident were arranged.
Continue-LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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-20220225085646

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CNS COURTYARD #146	FACILITY NUMBER: 019200487
	VISIT DATE: 08/22/2022

NARRATIVE

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Allegation: Personal Right - Staff are not meeting resident's dietary needs-Unsubstantiated
The Department has investigated this allegation and per record review and interviews found that resident’s care plan indicated that staff developed (with the resident) the shopping / menu list, then accompany the resident to the store to make the purchases. Review of receipts showed that resident purchased foods representing a well - rounded diet and representing all major food groups.

Allegation: Personal Right - Staff are not providing adequate laundry service for resident- Unsubstantiated
The Department has investigated this allegation and per record review and interviews found that the facility was regularly providing laundry service for the subject resident. During interview, the RP stated that the resident had a skin condition/rash that required items such as towels and bathmats to be washed separately from clothing. There was no discussion of this need in the Needs and Services Plan, Admission Agreement, or medical documents. Further, the MD evaluations from 7/25/2019 and 7/30/2019 specifically stated that the subject resident did not have a skin condition or a rash present.

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

No deficiency cited. Exit interview conducted with Administrator and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC9099 (FAS) - (06/04)

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