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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200873
Report Date: 11/19/2020
Date Signed: 11/19/2020 05:53:28 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
06/22/2020 and conducted by Evaluator Celia Phomphachanh
COMPLAINT CONTROL NUMBER: 15-AS-20200622141830
FACILITY NAME:POINT AT ROCKRIDGE, THEFACILITY NUMBER:
019200873
ADMINISTRATOR:SAVOIE, DEBORAHFACILITY TYPE:
740
ADDRESS:4500 GILBERT STREETTELEPHONE:
(510) 658-9266
CITY:OAKLANDSTATE: CAZIP CODE:
94611
CAPACITY:186CENSUS: 139DATE:
11/19/2020
UNANNOUNCEDTIME BEGAN:
04:45 PM
MET WITH:Deborah Savoie, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility did not obtain consent for medical treatment from responsible party.
Facility staff forced resident to submit medical procedure.
INVESTIGATION FINDINGS:
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On Thursday, November 19, 2020, Licensing Program Analyst (LPA) C. Phomphachanh called facility to deliver the findings for the above allegations. LPA spoke with Executive Directorn(ED), Deborah Savoie. Due to the Executive Order, Shelter in Place, set forth by the Govenor, LPA was not able to deliver the findings in person.

During the course of the investigation, the Department conducted interviews with Reporting Party (RP), staff and resident.

Allegation: Facility did not obtain consent for medical treatment from responsible party. The Department conducted interviews with RP and S1; S1 confirmed that the facility did not contact the subject resident’s responsible party to obtain consent for a medical procedure. SUBSTANTIATED.

Continuation on LIC 9099C - Page 1 of 2 Complaint Investigation
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2020
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-20200622141830
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
VISIT DATE: 11/19/2020
NARRATIVE
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Page 2 of 2 Complaint Investigation

Allegation: Facility staff forced resident to submit to medical procedure. The Department conducted interviews with RP, S1, R1 and a neutral witness; all confirmed that the subject resident was forced to undergo a medical procedure after expressing refusal. The Facility self-reported the incident to CCLD prior to receipt of the complaint. SUBSTANTIATED.

The Department has investigated the above allegations and per interviews conducted and records reviewed, the preponderance of evidence standard has been met and both are substantiated. Deficiencies are cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction by plan of correction due date and any repeat violations within 12-month period may result in civil penalties.

Exit interview conducted with Executive Director, Deborah Savoie. Appeal Rights and copy of this report provided via PDF email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20200622141830
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: POINT AT ROCKRIDGE, THE
FACILITY NUMBER: 019200873
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2020
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all the following personal rights:(1) To be accorded dignity in their personal relationships with staff, resident, and other persons.
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Administrator will submit a self-certification indicating that Administrator went over regulation 87468.1(a)1 and understand the Personal Rights of Residential in All Facilities.
Administrator will submit proof to CCL by POC date 12/04/202.0
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This requirement was not met as evidenced by:

Based on interviews, S1 did not treat R1 with dignity and accorded which poses a potential health and safety risk to residents in care.
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Type B
12/04/2020
Section Cited
CCR
80072(a)(9)
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80072 Personal Rights (a)... each client shall have personal rights which include, but are not limited to, the following: (9) To receive or reject medical care, or health-related services, except for minors and other clients for whom a guardian, conservator, or other legal authority has been appointed.
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Administrator will write a self-certification to CCL acknowledging that Administrator has reviewed Resident's Personal Rights. Administrator will submit self-certification to CCL by .12/04/2020.
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This requirement was not met as evidenced by:

Based on interviews, RP, S1, R1 and neutral witnesses, all confirmed that medical treatment was forced upon to R1 which poses an potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3