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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601182
Report Date: 03/21/2022
Date Signed: 03/21/2022 03:57:41 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
06/11/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210611161515
FACILITY NAME:PALM GARDEN HOME CAREFACILITY NUMBER:
075601182
ADMINISTRATOR:GUIJO, FLORANTE & VERONICAFACILITY TYPE:
740
ADDRESS:280 ELSIE DRIVETELEPHONE:
(925) 855-0400
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 0DATE:
03/21/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Julietta Extra, Back-up AdministratorTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Questionable deaths
Facility retained resident with restricted health conditions
Facility did not meet reporting requirements
Facility staff not fingerprint cleared
Resident was given wrong medication

INVESTIGATION FINDINGS:
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On 3/21/2022 starting at 12:40 PM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to deliver findings for the above allegation. LPAs met with Licensee Veronica Guijo and Back-up Administrator Julieta Extra and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, collected documents and interviewed staff.

Allegation: Questionable Deaths

Based on information obtained, two residents passed away in May 2021. However, interview with S1 and observation, 1 of 2 residents mentioned was observed at the facility. R1 was receiving hospice care and passed away on June 4, 2021.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
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-20210611161515
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: PALM GARDEN HOME CARE
FACILITY NUMBER: 075601182
VISIT DATE: 03/21/2022
NARRATIVE
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Allegation: Facility retained resident with restricted health conditions

Based on information obtained, resident is receiving injections by staff. However, based on record review and interview with S1, no residents required any injections.

Allegation: Facility did not meet reporting requirements

However, LPA obtained a copy of R1's death report. LPA was unable to obtain additional information from reporting party.

Allegation: Facility staff not fingerprint cleared

However, based on record review, LPA observed all staff were fingerprint cleared. LPA was unable to obtain additional information from complainant.

Allegation: Resident was given wrong medication

LPAs interviewed 3 staff and 3 of 3 staff stated they did not administer the wrong medication. LPA was unable to prove or disprove allegation. No forthcoming information was provided to LPA by complainant.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.




SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2