019200531-3-30-2023-15-AS-KHOS-CQRNRG-20230410104130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200531
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:58:37 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
02/10/2023 and conducted by Evaluator Lisha Holmes

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230210085223

FACILITY NAME:	ANGELS WINDSOR HOUSE		FACILITY NUMBER:	019200531
ADMINISTRATOR:	HAIDIE BAUTISTA		FACILITY TYPE:	740
ADDRESS:	2741 HILLEGASS AVENUE		TELEPHONE:	(510) 845-1850
CITY:	BERKELEY	STATE: CA	ZIP CODE:	94705
CAPACITY:	15	CENSUS: 15	DATE:	03/30/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Melanie Sison, Caregiver		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff leaves resident in soiled diapers for an extended period of time resulting in skin breakdown and ulceration

INVESTIGATION FINDINGS:

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On 03/30/23 at 03:30 PM, Licensing Program Analyst (LPA) L. Holmes arrived unannounced to deliver the findings for the above allegation. Upon arrival, LPA met with Melanie Sison, Caregiver and explained to the reason for the visit. Haidie Bautista, Administrator (ADM) was telephoned by the Caregiver and agreed that Caregiver can sign the report.

During the course of the investigation, LPA obtained information, collected documents, reviewed records, interviewed staff, witnesses, and Resident #1 (R1). It was alleged that facility staff leaves resident in soiled diapers for an extended period of time resulting in skin breakdown and ulceration. Based on LPA’s observations, record reviews and interviews with ADM, Staff (S1, S2), Witnesses (W1, W2), and R1, it was revealed that R1 was seen at LifeLong Brookside San Pablo Health Center in San Pablo, CA for a primary care visit on 12/21/22 from a prior fall.
...continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

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-20230210085223

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: ANGELS WINDSOR HOUSE	FACILITY NUMBER: 019200531
	VISIT DATE: 03/30/2023

NARRATIVE

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...continued from LIC 9099

Due to the change in R1’s heath condition and as a result, R1 was transferred to Elmwood SNF in Berkeley, CA on 12/23/22; R1 was discharged on 02/02/23. Doctor’s progress notes on 02/05/23 and 02/07/23 revealed that wound care, diaper changing, moisture barriers for every incontinence change, and increased assistance would be needed for R1. W1 further confirmed that there had not been any evidence of abuse while R1 lived at the facility around 20 years and referrals for a higher level of care for two facilities were under review.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
Exit interview conducted and a copy of this report provided to Administrator.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Lisha Holmes	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023

LIC9099 (FAS) - (06/04)

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