019200661-10-14-2021-15-AS-KHOS-C7XKXV-20211019081811

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200661
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:52:58 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
09/23/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210923090729

FACILITY NAME:	ROSE GARDEN VISTA		FACILITY NUMBER:	019200661
ADMINISTRATOR:	HASMIN B KOO		FACILITY TYPE:	735
ADDRESS:	1615 HIGH STREET		TELEPHONE:	(510) 533-4929
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	15	CENSUS: 14	DATE:	10/14/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Haidie Bautista, Administrator		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff is withholding resident's medications
Staff is preventing resident to see therapist and physical therapist
Staff speaks inappropriately to resident
Staff will not allow resident to have walker prescribed by physician

INVESTIGATION FINDINGS:

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On 10/14/21 at 12:15PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit to deliver the findings of above allegations. LPA explained the reason for the visit with administrator.

Allegation: Staff is withholding resident’s medications
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, C1 confirmed with LPAs that she receives her medications daily, before or during breakfast and also in the late afternoon before dinner. LPAs reviewed the initialed medication administration records (MAR) showing client’s medications and dosages given by staff daily.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

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-20210923090729

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: ROSE GARDEN VISTA	FACILITY NUMBER: 019200661
	VISIT DATE: 10/14/2021

NARRATIVE

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Allegation: Staff is preventing resident to see therapist and physical therapist
Investigation Finding: UNSUBSTANTIATED
During visit, client (C1) stated to LPAs that she is able to see her doctors and case managers. She told LPAs that her social worker/case manager helps her schedule her doctors' appointments. She also stated that sometimes, the doctor would see her at the facility. Other times, C1 stated she goes to her scheduled doctor’s appointments on her own. In a letter dated 9/29/2021, C1's case manager stated that there is no standing order or referral for physical therapy for C1. C1 is meeting with her case managers 2 to 3 times per week to provide coaching, skills building and connection to resources.

Allegation: Staff speaks inappropriately to resident
Investigation Finding: UNSUBSTANTIATED
During visit, client (C1) told LPAs that staff treats her well and do not yell or scream at her. C1 confirmed with LPAs that staff does not speak inappropriately to her or other residents at the facility. Another client (C2) confirmed with LPAs during visit that staff does not speak inappropriately to C1 or other residents at the facility.

Allegation: Staff will not allow resident to have walker prescribed by physician
Investigation Finding: UNSUBSTANTIATED
During investigation, staff (S1) told LPAs that client (C1) came back from the hospital with a walker on 09/22/21. S1 requested C1 to give her a copy of the hospital discharge report showing the walker was prescribed by the doctor. C1 refused to give S1 a copy of the hospital discharge report. S1 told C1 that use of the walker on stairs leading to her bedroom is unsafe and that she might hurt herself. They had a heated exchange and C1 kept her walker. C1 told LPAs she used her walker only for one day. LPAs review of C1’s hospital discharge summary report dated 09/22/21 did not show a prescription for the walker received by C1 during an ER visit at the hospital. C1 was given pain medications per report and no prescription medication.

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 cited. Exit Interview conducted and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2021

LIC9099 (FAS) - (06/04)

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