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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200515
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:13:50 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
06/10/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210610100816
FACILITY NAME:ABIGAIL'S GUEST HOMEFACILITY NUMBER:
019200515
ADMINISTRATOR:AURELIA MENDOZAFACILITY TYPE:
740
ADDRESS:6372 ARLINGTON DRIVETELEPHONE:
(925) 216-2921
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:6CENSUS: 4DATE:
10/14/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Aurelia Mendoza, Administrator
Carlota Moises, Caregiver		TIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Resident developed pressure injury while in care.
Facility staff did not seek medical treatment for resident.
Resident left in soiled diapers.
INVESTIGATION FINDINGS:
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On 10/14/2022 at 10:15AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegations above. LPA met with caregiver, Carlota Moises. Administrator, Aurelia Mendoza arrived about an hour later.

During the investigation, LPA interviewed 4 staff and witnesses. LPA obtained and reviewed resident's file including physician's report, care plan, care notes, hospital documents, and home health information.

Resident developed pressure injury while in care.
Hospital documents indicated that R1 had skin excoriations on buttock. Interview with staff revealed that R1 had pressure injury off and on due to R1 scratching the area. Staff stated that gloves were put on R1 to prevent scratching and R1 is repositioned to prevent pressure injury. (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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
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-20210610100816
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: ABIGAIL'S GUEST HOME
FACILITY NUMBER: 019200515
VISIT DATE: 10/14/2022
NARRATIVE
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Facility staff did not seek medical treatment for resident.
Interview with staff revealed that R1 was vomiting and feeling weak. Staff called 911 and paramedics arrived to take R1 to the hospital.

Resident left in soiled diapers.
Interview with staff revealed that R1 is checked for incontinence care 3-4 times a day. S1 stated that R1 had bowel movement when paramedics were transferring R1, but paramedics did not allow staff to change R1's diaper. Interview with witness indicated that home health agency post hospitalization did not observe R1 in soiled diapers when home health nurse visited.

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

No deficiencies are being cited on this date.

Exit interview conducted with Aurelia Mendoza. 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: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2