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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600206
Report Date: 05/04/2021
Date Signed: 05/04/2021 03:07:27 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
08/14/2020 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20200814123921
FACILITY NAME:A & A CARE HOME IFACILITY NUMBER:
075600206
ADMINISTRATOR:BORJA, AMYFACILITY TYPE:
740
ADDRESS:521 FENWAY DRIVETELEPHONE:
(925) 210-0808
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 4DATE:
05/04/2021
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Amy Borja, AdministratorTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident developed pressure injury while in care.

Facility staff do not adhere to doctor's orders for the resident.
INVESTIGATION FINDINGS:
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On 05/04/2021 at 02:55pm, Licensing Program Analyst (LPA), L. Hall conducted an unannounced visit via telephone to deliver complaint findings of the above allegations. LPA spoke with Amy Borja, Administrator, and explained the reason for the call. LPA explained due to the present shelter-in-place order by the Governor, the complaint investigation is being done over the phone.

During the course of the investigation, LPA conducted telephone interviews with witnesses, staff, and R1. LPA obtained and reviewed charting notes, turning logs, and nurse’s reports from the facility. Interviews indicated that R1 pressure wounds were received while in care, but staff did not neglect to provide care. On 7/15/2020, R1 had a video visit with the doctor regarding wound.

Continued on LIC9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
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-20200814123921
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: A & A CARE HOME I
FACILITY NUMBER: 075600206
VISIT DATE: 05/04/2021
NARRATIVE
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Continued from LIC9099.

Health nurse visits started 7/19/2020. Nurse’s reports and facility’s charting notes starting 7/31/2020 indicated nurse gave orders for R1. On 8/7/2020 documents showed wounds were healing; therefore, staff was adhering to orders given for R1’s.

Therefore, based on interviews and record reviews the allegations are Unsubstantiated. Although the allegations may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur.

Exit interview was conducted and a copy of this report was emailed.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2