019200717-1-24-2023-15-AS-HHUL-CNGM6Y-20230127082042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200717
Report Date: 01/24/2023
Date Signed: 01/24/2023 04:22:02 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
12/17/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20201217113846

FACILITY NAME:	BAY HARBOUR CARE HOME		FACILITY NUMBER:	019200717
ADMINISTRATOR:	RIVAS, DANIELA		FACILITY TYPE:	740
ADDRESS:	510 CENTRAL AVE		TELEPHONE:	(510) 523-0113
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94501
CAPACITY:	0	CENSUS: 0	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	04:05 PM
MET WITH:	Daniela Johnson, Licensee		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident was isolated in her room.

Staff did not give medications to the resident.

Staff did not treat resident with dignity.

Facility failed to replace resident's bedroom furniture.

Resident not accorded privacy in telephone conversation.

INVESTIGATION FINDINGS:

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On 1/24/2023 at 03:00PM, Licensing Program Analyst (LPA) L. Hall spoke with Daniela (Rivas) Johnson, Licensee, and explained her the reason for the call. LPA further explained the findings for the allegations above and the report will be sent via email due to facility closure as of 9/13/2021. LPA is requesting Licensee to return a signed copy.

During the course of the investigation, the LPA A. Delmundo conducted interviews with staff, Reporting Party (RP), obtained and reviewed records. Based on interviews and record reviews the allegations are found to be Unsubstantiated.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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 3

Control Number 15-AS-20201217113846

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: 01/24/2023

NARRATIVE

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Continued from LIC9099.

Allegations: Resident was isolated in her room and Staff did not treat resident with dignity.

Based on interview and record review, Resident 1 (R1) was admitted into facility on 1/17/2020 and moved out of the facility on 12/14/2020. RP stated that prior to R1 being moved R1 was isolated in her room for nine (9) months and because of the isolation was not treated with dignity. However, based on interview with S1 the only time R1 was isolated was when she had a fever and was exposed to COVID. S1 also stated at the beginning of the pandemic R1 would come out of her room while wearing a mask. During record review LPA observed the facility was following guidance from Community Care Licensing PIN-20-23-ASC page 6.

Allegation: Staff did not give medications to the resident.

Based on interviews and record review R1 was under hospice care. RP stated during interview that R1 told him the medication wasn’t given. RP stated he did not know the name of the medication and was sure there was a doctor’s order. S1 stated during interview that the hospice agency stopped giving information regarding R1’s medications and staff was not able to give the new dosage until they received a doctor’s order. S1 also stated that there was one medication that was delivered but without a doctor’s order, therefore, the staff was not able to administer.

Allegation: Facility failed to replace resident's bedroom furniture.

Based on interviews RP and staff stated that the recliner was purchased by family. During interviews RP stated the facility didn’t replace the recliner and S1 stated the facility provides sitting chairs for residents. LPA reviewed regulation 87307 Personal Accommodations and Services and observed bedroom furniture shall include a chair. Therefore, the facility was not required to replace the recliner.

Continued on LIC9099C.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20201217113846

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: 01/24/2023

NARRATIVE

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Continued from LIC9099C.

Allegation: Resident not accorded privacy in telephone conversation.

Based on interview with RP the facility did not have knowledge of R1 moving and the only way possible the facility found out must have been from monitoring R1’s conversations. Based on interviews RP and staff indicated that R1 owned a cellular phone. S1 also stated during interview that R1 was able to use her personal cellular phone and speak to whomever at any time without assistance from staff, and R1 was moved without prior notice.

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

Exit interview conducted and a copy of this report provided via email to Daniela Johnson.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

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