<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601014
Report Date: 10/06/2021
Date Signed: 10/08/2021 02:20:11 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
12/16/2019 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20191216141054
FACILITY NAME:REYES GUEST HOMES-BELFORDFACILITY NUMBER:
075601014
ADMINISTRATOR:RAQUEL Y. COYLEFACILITY TYPE:
740
ADDRESS:2263 BELFORD DR.TELEPHONE:
(925) 280-9975
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94598
CAPACITY:6CENSUS: 6DATE:
10/06/2021
UNANNOUNCEDTIME BEGAN:
02:55 PM
MET WITH:Raquel Coyle/Administrator TIME COMPLETED:
03:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident (R1) sustained a broken hip while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
This report is an amendment to the LIC9099 report issued on February 12, 2020.

Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the amended LIC9099. LPA met with Raquel Coyle, administrator, and informed the purpose of visit,

Per interviews and records review, the subject resident (R1) had full bedrails installed on both sides of the bed with the resident not being bedridden nor on hospice; and the facility did not obtain the required approval for an exception from Community Care Licensing (CCL) to have them. R1’s LIC602A Physician’s Report did not indicate that R1 was unable to transfer to/from the bed without the rails. R1 attempted to exit the bed with the bedrails in place, causing a fall and fracture at the hip.

.....continued next page (9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 3
Control Number 15-AS-20191216141054
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: REYES GUEST HOMES-BELFORD
FACILITY NUMBER: 075601014
VISIT DATE: 10/06/2021
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
The Department has investigated the above allegation and determined that the preponderance of evidence standard has been met, therefore, the allegation is substantiated, and deficiency cited under Title 22 of the California Code of Regulations. A $500.00 immediate civil penalty is assessed. Failure to submit proof of correction by due date may result in additional civil penalty.

Deficiency, civil penalty and plan and proof of correction were discussed with Raquel Coyle.

Exit interview conducted. Appeal Rights, LIC421IM, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20191216141054
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: REYES GUEST HOMES-BELFORD
FACILITY NUMBER: 075601014
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2021
Section Cited
CCR
87608(a)(5)(B)
1
2
3
4
5
6
7
87608 Postural Supports
(a) .... Postural supports may be used under the following conditions.
(5)(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
1
2
3
4
5
6
7
License, administrator and staff to undergo a refresher training conducted by an authorized vendor and submit the following:
1. Proof of registration for training to be submitted by 10/07/2021.
2. Copies of training certificates to be submitted by 10/16/2021.

8
9
10
11
12
13
14
-This requirement is not met as evidenced by:
-Based on interviews and records review, the licensee did not comply with the section above by having a full bed rails in R1’s bed. R1 climbed up the bedrail resulting to a fall and R1 sustained fracture at the hip which posed immediate health and safety risks to person in care.

8
9
10
11
12
13
14
A $500.00 civil penalty is assessed,
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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3