075601182-12-6-2023-15-AS-YFLS-CYF2MY-20231211163156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601182
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:04:31 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
09/22/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210922074830

FACILITY NAME:	PALM GARDEN HOME CARE		FACILITY NUMBER:	075601182
ADMINISTRATOR:	GUIJO, FLORANTE & VERONICA		FACILITY TYPE:	740
ADDRESS:	280 ELSIE DRIVE		TELEPHONE:	(925) 855-0400
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	0	CENSUS: 0	DATE:	12/06/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Veronica Guijo, Licensee		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Resident sustained a fall resulting in injuries (fracture, bruise and scab) while in care.
Facility staff did not report resident's fall.
Facility staff did not obtain timely medical care for resident.
Facility staff did not notify resident's physician or responsible party regarding resident's change in condition.
Facility did not maintain a comfortable temperature for residents.
Facility staff member mismanaged resident's medication.
Facility staff member yelled at resident.
Facility did not feed resident nutritious meals.

INVESTIGATION FINDINGS:

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On 12/6/23 at 11:44 AM, Associate Governmental Program Analyst (AGPA) L. Francisco called Licensee to deliver findings for the above allegations over the phone due to facility being closed. AGPA spoke to Licensee over the phone, and Licensee requested for AGPA to email report.

During the course of the investigation, LPA obtained information, collected documents, reviewed records and interviewed staff and attempted to interview residents. It was alleged resident sustained a fall resulting in injuries (fracture, bruise, and scab) while in care, and facility staff did not obtain timely medical care for resident. LPA reviewed R1's discharged notes from 8/10/21 and observed R1 sustained a hip fracture. However, based on interview with 2 staff (S1 and S2) and record review of incident report, when R1 yelled for help, S2 responded to R1 and observed R1 sitting on the recliner. S2 stated S2 assessed R1 and R1 did not recall what happened. Record review of incident report indicated that facility contacted R1's responsible party.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

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-20210922074830

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PALM GARDEN HOME CARE	FACILITY NUMBER: 075601182
	VISIT DATE: 12/06/2023

NARRATIVE

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S1 stated staff observed no bruising on R1 and R1 denied of pain. During record review of discharge notes, LPA L. Francisco observed R1 has a history of osteoporosis. S1 stated R1 is being seen by a physical therapist due to history of falls prior to being admitted to the facility. LPA was unable to prove or disprove allegation.

It was alleged facility did not maintain a comfortable temperature for residents. However, during LPA L. Francisco's visit on 10/1/2021, LPA observed room temperature maintained at 71 degrees F. LPA L. Francisco attempted to interview R2, but was unable to obtain additional information. S1 and S2 stated if room temperature is hot, then air conditioning will be turned on. LPA was unable to prove or disprove the allegation.

Facility staff member mismanaged resident's medication. Based on record review of R1's centrally stored medication and destruction record, LPA observed Seroquel is to be given 1/2 tab (2 times a day) to R1. S1 denied increasing the dose. LPA was unable to obtain a copy of a doctor's order regarding the increase.

It was alleged facility staff member yelled at resident. LPA interviewed 2 staff, 2 of 2 staff denied allegation. LPA attempted to interview R2, but was unable to obtain additional information.

Facility did not feed resident nutritious meals. However, interview with S2 revealed that R1 will request a cup of noodles to eat. On 10/1/2021, LPA inspected food supply and observed including but not limited to the following: vegetables, fruits, dairy, meat, and poultry.

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

AGPA emailed report to Licensee for signature per Licensee's request.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2023

LIC9099 (FAS) - (06/04)

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