019200544-5-5-2021-15-AS-KHOS-C3SKFQ-20210608075217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200544
Report Date: 05/05/2021
Date Signed: 05/05/2021 04:17:05 PM

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
07/22/2020 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20200722132324

FACILITY NAME:	AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY		FACILITY NUMBER:	019200544
ADMINISTRATOR:	ALBERT LEANO		FACILITY TYPE:	740
ADDRESS:	23652 NEVADA ROAD		TELEPHONE:	(510) 314-0807
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94541
CAPACITY:	6	CENSUS: 4	DATE:	05/05/2021
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Helen Macatangay/Licensee		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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-Resident (R1) sustained injuries while in care.

-Resident (R1) suffered medical complications while in care.

INVESTIGATION FINDINGS:

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On this day, May 5, 2021, Licensing Program Analyst (LPA) Delmundo spoke with Helen Macatangay, licensee, and informed the reason for call. LPA further informed that due Shelter in Place Order by the Governor and management directive to telework, LPA is delivering the findings to the allegations via televisit.

The complaint was received on July 22, 2020. It was alleged that R1 sustained injuries while in care and went into a septic shock. It was also alleged that R1’s ammonia level was high.

During the course of the investigation, the Department conducted interviews with staff (S1, S2 and S3), resident’s responsible person (FM1) and an individual (W1) who does not have affiliation but have come to visit other resident in the facility. The Department also obtained R1’s documents, and home health and medical records.

......continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

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-20200722132324

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: AIC RESIDENTIAL CARE FACILITY FOR THE ELDERLY	FACILITY NUMBER: 019200544
	VISIT DATE: 05/05/2021

NARRATIVE

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R1 was admitted to the facility with pre-existing injuries in arms and legs. Records showed R1 was at this facility for one month. Home Health nurse (HH1) made multiple visits and R1 had a telephone visit with a doctor on June 2020. HH1 addressed R1's medical needs which included skin/wound assessment, and medications management for each visit. HH1 provided additional intervention needed, and updated R1’s doctor with each visit. On HH1’s last visit, HH1 did not have concerns about R1's health. Facility progress notes described arm blisters; however, HH1 did not note any blisters. R1 was assessed by another home health agency (HH2) in July 2020 with primary diagnosis of hypertensive heart with heart failure and other diagnosis such as sepsis and abrasion on leg and other medical issues. No follow-up visit was made by HH2 after the assessment as R1 was sent out to the hospital and did not return to this facility.

R1 had pre-existing conditions that made her susceptible to high ammonia levels. R1 was prescribed lactulose as R1 needed to defecate 4x a day to excrete the ammonia. R1’s wound care team and R1’s family note that it was difficult for R1 to have 4 bowel movements a day. Per wound care team, R1 is medically fragile, has history or pancytopenia and platelets are low. R1’s wound team believes that suspicion for abuse/neglect was undetermined at the that time. FM1 was interviewed who indicated she does not have any concern on how the facility took care of R1 which collaborated with medical social worker’s note. W1 indicated she visited the facility multiple times and did not have issues.

Based on all information obtained by the Department, the allegations are unsubstantiated. An unsubstantiated finding 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.

Exit interview conducted and copy of this report provided to Helen Macatangay via e-mail.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2021

LIC9099 (FAS) - (06/04)

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