019200717-10-9-2020-15-AS-KHOS-BUKQ8U-20201020115720

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200717
Report Date: 10/09/2020
Date Signed: 10/09/2020 03:17:41 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
09/05/2019 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20190905162901

FACILITY NAME:	BAY HARBOUR CARE HOME		FACILITY NUMBER:	019200717
ADMINISTRATOR:	JOHNSON, DANIELA TERESA		FACILITY TYPE:	740
ADDRESS:	510 CENTRAL AVE		TELEPHONE:	(510) 205-1731
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94501
CAPACITY:	12	CENSUS: 3	DATE:	10/09/2020
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Daniela Rivas, Administrator Bernadette Hunsaker, Resident Care Coordinator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Resident sustained injury while in care

INVESTIGATION FINDINGS:

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On 10/9/2020 at 2:50PM, Licensing Program Analyst (LPA) G. Luk contacted facility to delivery finding for the above allegation via Tele-Visit due to shelter in place directed by the Governor. LPA conducted Tele-Visit via FaceTime with Administrator, Daniela Rivas and Resident Care Coordinator, Bernadette Hunsaker.

During the investigation, LPA interviewed 5 staff, hospice nurse, and complainant. LPA obtained and reviewed resident's physician's report, appraisal, caregiver's notes, and hospice care plan.

Interview with staff revealed that R1 had an unwitnessed fall on 7/26/2019 and sustained injuries on the face. S1 stated that R1 had soft bumpers along the bed rails, but R1 pulls them down.

(Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

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-20190905162901

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: BAY HARBOUR CARE HOME	FACILITY NUMBER: 019200717
	VISIT DATE: 10/09/2020

NARRATIVE

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Interview with H1 indicated that R1 was prone to bruising and is a slow healer. H1 stated that R1 had a fall in July 2019 and injured the left eye.

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

No deficiencies are being cited on this date.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/09/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020

LIC9099 (FAS) - (06/04)

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