075601221-2-8-2023-15-AS-KHOS-CPAUF8-20230222143220

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601221
Report Date: 02/08/2023
Date Signed: 02/08/2023 05:51:19 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
02/02/2023 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20230202115742

FACILITY NAME:	LARKEY PARK HOME CARE		FACILITY NUMBER:	075601221
ADMINISTRATOR:	CAMACLANG, ALBERTINA R		FACILITY TYPE:	740
ADDRESS:	2532 LARKEY LANE		TELEPHONE:	(925) 287-8590
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	6	CENSUS: 3	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	CAMACLANG, ALBERTINA R, Administrator		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Staff failed to notify authorized representative of resident hospitalization & Staff failed to report incidents to licensing timely

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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-20230202115742

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: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
	VISIT DATE: 02/08/2023

NARRATIVE

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Based on interview, Administrator admitted that when R1 was hospitalized, S2 attempted to call R1’s responsible party to report about the incident but unfortunately the phone numbers listed on R1’s chart was incorrect and responsible party was not aware of the incident not until hospital staff called R1’s responsible party.

Based on records review, S1 provided a copy of unusual incident report to LPAs that was found on R1’s chart, but Administrator failed to provide proof that this unusual incident report with incident dated 11/22/2022 was sent to CCL.

Based on information obtained, the preponderance of evidence is met, therefore the allegation is substantiated.

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

Deficiency and plan of correction were discussed with Administrator.

Exit interview conducted, Appeal Rights, LIC9099D, and a copy this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20230202115742

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: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/24/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements. A written report shall be submitted to the licensing agency...within seven days of the occurrence of any of the events specified... This requirement was not met as evidence by:	1 2 3 4 5 6 7	Licensee has agreed to review reporting requirements and submit self-certification to CCLD by POC date.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not submitting incident report to CCLD and failed to notify R1's responsible party in timely manner about her hospitalization which poses a potential health and safety risk to the residents 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/02/2023 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20230202115742

FACILITY NAME:	LARKEY PARK HOME CARE		FACILITY NUMBER:	075601221
ADMINISTRATOR:	CAMACLANG, ALBERTINA R		FACILITY TYPE:	740
ADDRESS:	2532 LARKEY LANE		TELEPHONE:	(925) 287-8590
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	6	CENSUS: 3	DATE:	02/08/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	CAMACLANG, ALBERTINA R, Administrator		TIME COMPLETED:	06:10 PM

ALLEGATION(S):

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Lack of care and supervision resulting in resident unwitnessed fall while in care
Staff failed to follow physicians’ medication order for resident in care
Staff failed to arrange medical care appointment to resident in care
Staff failed to ensure pathways are free from obstructions and tripping hazard
Staff are not meeting resident's hygiene needs
Staff failed to provide proper bedroom furniture to resident in care
Facility failed to provide sufficient staffing for resident in care
TV is inoperable

INVESTIGATION FINDINGS:

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On 02/08/2023 at 12:05PM, Licensing Program Analysts (LPAs) L. Ibo and L. Alexander arrived unannounced a subsequent complaint visit to investigate the above allegations. LPAs met with Administrator and informed the purpose of visit.

During the course of investigation, LPAs interviewed residents and staff. LPAs obtained and reviewed documents including physician's report, admission agreement, medication administration records (MAR), resident’s rooster, staff schedule with staff names and phone numbers.

Lack of care and supervision resulting in resident unwitnessed fall while in care
Based on records review and interview, on 11/22/2022 R1 had an unwitnessed fall while she was in her bedroom, when R1 called for help, staff checked on R1 right away and staff called 9-1-1. Interview and records review stated that there was no injury resulted on this fall incident. Based on R1’s care plan and pre-appraisal needs and services R1 was not under one-on-one care. …Continue to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20230202115742

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: LARKEY PARK HOME CARE	FACILITY NUMBER: 075601221
	VISIT DATE: 02/08/2023

NARRATIVE

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Staff failed to follow physicians’ medication order for resident in care

Based on records review and interview, the staff are following the doctor’s order in terms of assisting residents on their medications. Medication Administrator Records (MAR) revealed that there were no missed medications. There was no incident report of any missed medication or wrong medication given to residents in care.

Staff failed to arrange medical care appointment to resident in care

Based on interview and records review; admissions agreement records stated that facility will help, arrange transportation for medical and dental appointments. If the facility will provide this service an additional cost will be added to resident’s bill. Staff interview revealed that, Administrator was assisting R1 on her doctor’s appointments by driving R1 to the doctor’s office and those appointments are all communicated with R1’s responsible person.

Staff failed to ensure pathways are free from obstructions and tripping hazard

LPAs toured the facility inside and outside and it was observed that facility’s pathways were free from obstructions and there was no tripping hazard observed during the visit.

Staff are not meeting resident's hygiene needs

Based on interview and observation; LPAs observed that the residents do not have evidence of foul-smelling odor, residents were wearing clean clothing, no evidence that hygiene needs are not being met on residents in care. Resident’s interview revealed that they are comfortable living at the facility, staff are assisting them on their hygiene needs.

Staff failed to provide proper bedroom furniture to resident in care

Based on LPAs observation, there was proper bedroom furniture to residents in care such as a chair, nightstand, a lamp, or lights sufficient for reading, and a chest of drawers.

Facility failed to provide sufficient staffing for resident in care

LPAs reviewed staff schedule for the facility, facility had sufficient staffing for all shifts. LPAs conducted interview and based on the interview, there are two (2) available staff in all shifts. Residents were observed calm and comfortable in their surroundings. LPAs conducted interview with resident and resident reported that they are happy living at the facility and had no issues around staff availability to meet their needs. R2 reported that facility staff attend to his needs.

TV is inoperable

Based on interview, R1’s family brought a TV for R1 to use in her room. Administrator stated that the TV was working but she was not aware that if the TV at the family room is on then the TV on R1’s room can’t be able to use because of an issue of digital cable box. When Administrator found out the issue, she instructed the staff to turn off the family room TV if R1 wants to use her TV in her room since all residents bedrooms have their own TVs.

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

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC9099 (FAS) - (06/04)

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