019201167-7-31-2023-15-AS-KHOS-CURRJS-20230816130426

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019201167
Report Date: 07/31/2023
Date Signed: 07/31/2023 03:31:29 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
01/30/2023 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20230130112801

FACILITY NAME:	ELEGANCE AT DUBLIN		FACILITY NUMBER:	019201167
ADMINISTRATOR:	ESPINOZA, MARISSA K		FACILITY TYPE:	740
ADDRESS:	7601 AMADOR VALLEY ROAD		TELEPHONE:	(360) 836-4604
CITY:	DUBLIN	STATE: CA	ZIP CODE:	94568
CAPACITY:	80	CENSUS: 46	DATE:	07/31/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Marissa Espinoza, Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple injuries from a fall while in care
Staff did not provide adequate supervision to a resident while being transported
Staff are denying an authorized representative access to incident report
Staff did not seek timely medical attention for a resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 7/31/2023 at 3:30PM, Licensing Program Analyst (LPA) K. Nguyen delivered finding for the allegations above. LPA met with Marissa Espinoza, administrator and explained the purpose of the visit.

It was alleged that Resident sustained multiple injuries from a fall while in care. Base on recorded review of discharge summary. R1 was diagnose with skull fracture, however interviewed conducted with S1, S2, S3, and S4, it was revealed that it was not due to lack of supervisions or neglect. On 1/24/23 at 12am S3 and S5 conducted their routine checked and observed R1 sleeping. At 12:30am S3 heard R1 yell came to R1 found R1 on the floor. S3 assessed R1 and called 911 immediately. R1 service care plan does indicate that R1 is fall risk with some supervision with daily reminders, and frequent check in. Recorded reviews indicate that R1 do not have multiple incidents in the past month. Unsubstantiated

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

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 2

Control Number 15-AS-20230130112801

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: ELEGANCE AT DUBLIN	FACILITY NUMBER: 019201167
	VISIT DATE: 07/31/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

It was alleged that staff does not provide adequate supervision to a resident while being transported, however on 2/7/23 during the course of the investigation, LPA interviewed S3; S3 stated “I heard a yell from R1 room. I came to R1 room and found R1 on the floor. I immediately assessed R1, and immediately call 911”. S3 assisted R1 while waiting for EMT to arrive to transport R1 to the hospital. S3 states “I never left R1 side until R1 is safely being transport by the EMT”. On 2/7/23, LPA interviewed RP who stated that staff did not accompany the resident on the emergency vehicle nor follow behind, however there is no regulation requiring staff to do so. Unsubstantiated

It was alleged that staff are denying an authorized representative access to incident report. On 2/7/23 LPA interviewed RP who stated, “RP wanted to obtained documents regarding R1 incident, but S1 refused to provide RP with the information”. However, on 2/7/23 LPA interviewed S1 who stated “I attempt to call RP back, left a message, and email requesting for RP to call back to clarified which documents. I never heard back from RP”. LPA reviewed and obtained email communications log/call log showed that S1 attempted to reached out to RP, but RP didn’t response back. Unsubstantiated

It was alleged that staff did not seek timely medical attention for R1. On 2/7/23 LPA interviewed S3 states “at 12:30am right when I heard R1 yelled out that’s when I came to R1 room and assessed R1 and called 911 immediately”. Unsubstantiated

Based upon interviews conducted, LPA has investigated the above allegation and found that it is Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2