075601281-8-5-2022-15-AS-KHOS-CHCJEH-20220816065909

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601281
Report Date: 08/05/2022
Date Signed: 08/05/2022 05:35:04 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
06/29/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220629143244

FACILITY NAME:	QCARE RESIDENTIAL FACILITY II		FACILITY NUMBER:	075601281
ADMINISTRATOR:	CUNANAN, JOAQUIN		FACILITY TYPE:	740
ADDRESS:	4363 FAIRWOOD DRIVE		TELEPHONE:	(925) 676-8727
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 5	DATE:	08/05/2022
		UNANNOUNCED	TIME BEGAN:	04:53 PM
MET WITH:	Joaquin Cunanan, Administrator		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Staff inappropriately recorded resident

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

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 5

Control Number 15-AS-20220629143244

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: QCARE RESIDENTIAL FACILITY II	FACILITY NUMBER: 075601281
	VISIT DATE: 08/05/2022

NARRATIVE

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Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the allegation that staff inappropriately recorded resident was found to be substantiated.
Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 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
06/29/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220629143244

FACILITY NAME:	QCARE RESIDENTIAL FACILITY II		FACILITY NUMBER:	075601281
ADMINISTRATOR:	CUNANAN, JOAQUIN		FACILITY TYPE:	740
ADDRESS:	4363 FAIRWOOD DRIVE		TELEPHONE:	(925) 676-8727
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 5	DATE:	08/05/2022
		UNANNOUNCED	TIME BEGAN:	04:53 PM
MET WITH:	Joaquin Cunanan, Administrator		TIME COMPLETED:	05:50 PM

ALLEGATION(S):

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Resident sustained injury while in care resulting in a bruised nose
Staff are not able to meet resident’s needs

INVESTIGATION FINDINGS:

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On 08/05/22 at 4:53PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident sustained injury while in care resulting in a bruised nose
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) has dementia with sundowning syndrome, confused, hallucinates, a fall risk and would constantly attempt to get out of bed. LPA interviewed staff who stated R1 may have accidentally bruised his nose hitting his bed rail while trying to get out of bed. Staff denied pinching R1’s nose. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident sustained injury while in care resulting in a bruised nose is unsubstantiated.
Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 15-AS-20220629143244

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: QCARE RESIDENTIAL FACILITY II	FACILITY NUMBER: 075601281
	VISIT DATE: 08/05/2022

NARRATIVE

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Allegation: Staff are not able to meet resident’s needs
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was admitted at the facility on 02/03/22 and was relocated to another facility on 04/19/22. During R1’s stay at the facility, staff stated R1 was a fall risk, highly agitated, confused, hallucinating, a combative sundowner and incessantly attempts to climb out of bed. Staff stated they changed R1’s diaper 5 to 8 times daily with wash-ups and periodic attempts to turn and sit him up for socialization with other residents.

Review of medication administration records show that staff followed doctor’s prescribed medications for R1 including Zoloft. R1 also had therapy exercise sessions (Mondays & Wednesdays) at the facility for 30 to 45 minutes with a massage therapist with staff helping R1 exercise on days that the therapist was not visiting. A change in prescription medication was subsequently ordered by R1's doctor early April 2022 from Zoloft to Seroquel to aid in R1's worsening nightly agitation as reported to POA by staff.

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

Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20220629143244

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: QCARE RESIDENTIAL FACILITY II	FACILITY NUMBER: 075601281
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/05/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2022 Section Cited CCR 87468.1(1)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	By POC due date, Administrator agreed to complete and submit to CCLD a copy of staff retraining certification by an approved CCLD vendor on residents’ personal rights.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by the unauthorized recorded video of R1 which posed a potential health & safety risk to 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5