075600618-8-11-2021-15-AS-KHOS-C67PYS-20210824114421

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075600618
Report Date: 08/11/2021
Date Signed: 08/11/2021 01:33:51 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
08/02/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210802105757

FACILITY NAME:	ABRAHAM REST HOME		FACILITY NUMBER:	075600618
ADMINISTRATOR:	ANNETTE SANCHEZ		FACILITY TYPE:	740
ADDRESS:	2832 FILBERT AVENUE		TELEPHONE:	(925) 287-8382
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 5	DATE:	08/11/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Annettte Sanchez/Licensee-Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident (R1) has taken other resident's medications,

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Alicia Delmundo and Catherine LIn arrived unannounced to conduct investigation of the above allegation. LPAs met with staff, Linda Kengne and Sarah Nakiwala. LPA called and spoke with Annettte Sanchez, licensee-administrator, and informed the purpose of LPAs' visit. Annette arrived after about fourty minutes. LPAs also met with Sarah Abraham, assistant manager.

LPAs reviewed residents' file, and conducted interviews and inspection. LPA obtained copies of the following resident's documents: LIC602A Physician's Report; doctor's order of medications; Medication Administration Records; LIC622 Centrally Stored Medication and Destruction Record.

LPA Delmundo reviewed the incident report submitted by Annette Sanchez to Community Care Licensing dated July 29, 2021.

....continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210802105757

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: ABRAHAM REST HOME	FACILITY NUMBER: 075600618
	VISIT DATE: 08/11/2021

NARRATIVE

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Review of R1's Physician's Report revealed R1 needs assistance on administration of medications.

During interview, Annette Sanchez indicated she was at the facility when the incident happened when R1 has taken the medications for R2. Staff S1 was to administer medications to R2 when R1 called for help. S1 brought R2's medications and placed on top of a cup board in R1's room, and R1 took R2's medications. These collaborated with S1's statement.

Based on the information obtained that staff brought R2's in R1's room when R1 called for help and R1 took R2's medications, the allegation is substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 California Code of Regulations (see 9099D). Failure to submit proof of correction (POC) by plan of correction due date and any repeat violations within 12 month period may result in civil penalties.

Deficiency and plan and proof of correction were discussed with Annette Sanchez and Sarah Abraham.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided to Sarah Abraham.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20210802105757

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: ABRAHAM REST HOME	FACILITY NUMBER: 075600618
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/12/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (a)........ (5) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to in-service the staff and submit proof by 8/12/2021.
	8 9 10 11 12 13 14	-Based on review of records and interview, the licensee did not comply with the section cited above. Staff brought R2's medications in R1's room which R1 has taken. This posed immediate health risk to person in care,	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021

LIC9099 (FAS) - (06/04)

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