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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075600400
Report Date: 05/31/2024
Date Signed: 05/31/2024 04:35:18 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
05/03/2023 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20230503081459
FACILITY NAME:DELL'S RESIDENTIAL HOMEFACILITY NUMBER:
075600400
ADMINISTRATOR:MITCHELL, TRACYFACILITY TYPE:
735
ADDRESS:4444 BELLE DRIVETELEPHONE:
(925) 978-0345
CITY:ANTIOCHSTATE: CAZIP CODE:
94509
CAPACITY:4CENSUS: 4DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ricky Hazan, Direct Support ProfessionalTIME COMPLETED:
04:50 PM
ALLEGATION(S):
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Resident sustained an unexplained fracture while in care.

Resident developed stage 3 pressure injury while in care due to staff neglect.

Staff did not seek timely medical attention for resident's serious injury.
INVESTIGATION FINDINGS:
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On 5/31/2024 at 03:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Ricky Hazan, Direct Support Professional (DSP). LPA spoke with listed Administrator, Tracy Mitchell, via telephone and explained the reason for the visit. Listed Adminsitrator gave approval for DSP to sign documents.

The Department interviewed the reporting party (RP), a client, former and present staff, obtained and reviewed records. The records reviewed included Client 1 (C1’s) admission agreement, appraisal needs and services, identification and emergency contact, physician's report (LIC602), case/progress notes, incident reports for 2023, medical records, personnel record (LIC500), client roster, and Individual Program Plan (IPP).

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
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-20230503081459
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: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
VISIT DATE: 05/31/2024
NARRATIVE
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Continued from LIC9099.

Allegation: Resident sustained an unexplained fracture while in care.

On July 20,2023, the Department obtained and reviewed C1’s medical records which indicated that C1 was admitted to Sutter Delta Medical Center Surgical Care Unit for pain in his left foot on April 14, 2023, and was discharged the same day. C1 was diagnosed with a displaced fracture in his foot. On April 26, 2023, C1 returned to Sutter Delta Medical Center and was diagnosed with a right-hand scaphoid fracture. Interviews with staff revealed consistent statements of being unable to communicate with C1 regarding pain or hurt, due to C1 being non-verbal. Interviews also indicated staff did not know how C1 sustained fractures, but assumed it was from C1 falling even though the staff did not witness any falls.

Allegation: Resident developed stage 3 pressure injury while in care due to staff neglect.

On April 26, 2023, C1 was admitted to Sutter Delta Medical Center and seen by a wound care registered nurse due to his blisters. C1 had a right forearm blister, a right thigh blister, and a coccyx stage three pressure wound. C1 was diagnosed with systemic inflammatory response syndrome and discharged to a skilled nursing facility on May 5, 2023. Interviews with staff indicated that S2 gave C1 daily showers. S2 admitted during an interview to seeing something on C1’s coccyx that appeared to be like a scar red colored but was not open. S2 also stated that he reported the coccyx blister and documented it on paper but was not certain who he told. S3 stated during an interview that she conducts daily body checks underneath the clients clothing but failed to notice C1 had a stage 3 pressure injury. S1 stated staff did not report any wounds until C1 was found to have blisters on his arm and thigh.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230503081459
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: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
VISIT DATE: 05/31/2024
NARRATIVE
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Continued from LIC9099C.

Allegation: Staff did not seek timely medical attention for resident’s serious injury.

Based on the investigation, C1 was taken to the hospital on 4/26/2023. The progress notes documented that S1 informed the hospital that C1 was brought to the hospital due to staff observing a blister on C1’s sacral area on 4/25/2023 which had popped and had redness surrounding it. The blister on C1’s right forearm had also popped with redness surrounding it and redness that is firm to touch in the right latter thigh area.

Staff interviews revealed the consistent procedure of noticing a client with any type of mark or injuries on their bodies and reporting immediately to either S1 or S2. S2 and S3 both stated having some prior knowledge (before 4/25/2023) of C1 developing stage three pressure injury but failed to document it or report it to S1. C1 did not get medical care until the pressure injury had worsened.

Deficiencies are cited under the California Code of Regulations, Title 22, Division 6, follows on LIC9099D.

*A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to injury of client is pending.*

Exit interview conducted. A copy of the appeal rights, LIC

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230503081459
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: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/01/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement was not met as evidence by:
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Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later.
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Based on record review and observation the Licensee did not comply with the section cited above in keeping meeting clients needs which poses an immediate health and safety risk to persons in care.
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Type B
06/07/2024
Section Cited
CCR
80075(a)
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80075 Health Related Services
(a) The licensee shall ensure that each client receives necessary... medical...including arrangement for and/or provision of transportation to the nearest available services. This requirement was not met as evidence by:
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Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later.
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Based on record review and observation the Licensee did not comply with the section cited above in ensuring client receives necessary care which poses/posed an immediate health and safety risk to persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230503081459
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: DELL'S RESIDENTIAL HOME
FACILITY NUMBER: 075600400
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/07/2024
Section Cited
CCR
80065(a)
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80065 Personnel Requirements
(a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.
This requirement was not met as evidence by:
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Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later.
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Based on record review and observation the Licensee did not comply with the section cited above in staff being able to meet the needs of the client which poses/posed an immediate health and safety risk to persons 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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5