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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200880
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:23:17 PM

Substantiated


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
08/18/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230818100718
FACILITY NAME:ARIZONA CARE HOMEFACILITY NUMBER:
019200880
ADMINISTRATOR:VALENCIA-GARCIA, LALLIEFACILITY TYPE:
735
ADDRESS:33051 ARIZONA STTELEPHONE:
(510) 489-2465
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
05/02/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosanna RefulgenteTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff left resident unattended resulting in resident falling.
INVESTIGATION FINDINGS:
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On this day at around 2:30 pm, LPA Luisa Fontanilla arrived unannounced to deliver finding on the above allegation and met with staff Rosanna Refulgente. LPA explained to Refulgente the purpose of the visit. The Administrator was informed about the visit over the telephone. LPA discussed with the Administrator the findings. She authorized Refulgente to sign the report.

On 8/25/2023, LPA conducted 10-day investigation, interviewed staff and obtained records.
Based on interviews conducted, Staff 1 (S1) is the designated 1:1 for Client 1 (C1) from Monday-Friday, 7 am to 10 pm. S1 states that S1 would call or send a text message to Staff 2 (S2) in case S1 needed relief from providing care to C1.
On 5/27/2023, S1 left C1 in bed to get C1’s food from the kitchen. S1 admits to not calling or texting any other staff for relief. As soon as S1 left the room, S1 heard a loud sound coming from the room. S1 went back to C1’s room right away and found C1 on the floor. C1 lost one front tooth and two teeth were cut in half from the fall. continuation Lic 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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 5
Control Number 15-AS-20230818100718
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: ARIZONA CARE HOME
FACILITY NUMBER: 019200880
VISIT DATE: 05/02/2024
NARRATIVE
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Based on interviews conducted, the allegation “Staff left resident unattended resulting in resident falling” is substantiated. California Code of Regulations, Title 22 is being cited on the attached Lic 9099D.

Exit interview was conducted with the Administrator and Appeal Rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/18/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230818100718

FACILITY NAME:ARIZONA CARE HOMEFACILITY NUMBER:
019200880
ADMINISTRATOR:VALENCIA-GARCIA, LALLIEFACILITY TYPE:
735
ADDRESS:33051 ARIZONA STTELEPHONE:
(510) 489-2465
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 3DATE:
05/02/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Rosanna RefulgenteTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident in a timely manner.
Staff did not administer resident's medication as prescribed in a timely manner.
INVESTIGATION FINDINGS:
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On this day, LPA Luisa Fontanilla arrived unannounced to deliver findings on the above allegations and met with staff Rosanna Refulgente. LPA explained to Refulgente the purpose of the visit. The Administrator was notified about the visit. LPA explained to the Administrator findings. She authorized Refulgente to sign the reports.

Staff did not seek medical attention to resident in a timely manner.

During the course of investigation, LPA reviewed records and interviewed staff.
Based on interviews conducted, C1 experiences heavy monthly menstrual cycles. On July 18-24, 2023, C1 was having a heavy period. C1’s family gets notified each time C1’s menstrual cycle starts and ends. On July 26, C1’s father requested the Administrator that C1 be sent to the hospital. On July 27, C1 was brought to Kaiser Hospital Fremont and was admitted from July 27-31. C1 was transferred and admitted to Kaiser San Leandro from July 31-August 3 due to liver embolization. .

continuation on Lic 9099C

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230818100718
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: ARIZONA CARE HOME
FACILITY NUMBER: 019200880
VISIT DATE: 05/02/2024
NARRATIVE
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C1 was discharged back to the facility on August 3, 2023. On August 11, C1 was sent back to the hospital and was diagnosed with c-diff.


Staff did not administer resident's medication as prescribed in a timely manner.

A review of C1’s seizure chart from February 2022 to August 2023 indicates that C1’s seizures occurred at different times but mostly in the afternoon/evening. For the period reviewed, C1 had a total of 23 seizure episodes, 2 of which occurred in the morning and the rest in the afternoon/evening.
A review of C1’s doctor’s order for seizure medication indicates that C1 takes 3 capsules orally in the morning and 3 capsules in the evening. There is no target time indicated in the prescription order.

Based on records reviews and interviews conducted, the above allegations are unsubstantiated.

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

No deficiencies were noted.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230818100718
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: ARIZONA CARE HOME
FACILITY NUMBER: 019200880
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2024
Section Cited
CCR
85078(a)(1)
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85078 Responsibility for Providing Care and Supervision
(a) In addition to Section 80078, the following shall apply:
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs.
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The Administrator will review with all staff each client's needs as indicated in the service plan and submit self-certificate of completion to CCL by POC date.
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This requirement is not met as evidenced by:
Based on interviews and record reviews conducted, S1, who is C1’s 1:1 for the day left C1 in bed to get C1’s foods. C1 fell from the bed and lost one front tooth and two teeth were cut in half.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5