075601282-11-2-2022-15-AS-KHOS-CLVHDL-20221207050630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601282
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:42:59 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
05/20/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210520122215

FACILITY NAME:	QCARE RESIDENTIAL FACILITY III		FACILITY NUMBER:	075601282
ADMINISTRATOR:	CUNANAN, JOAQUIN		FACILITY TYPE:	740
ADDRESS:	4369 FAIRWOOD DRIVE		TELEPHONE:	(925) 682-0111
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 4	DATE:	11/02/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Estelita Calaguas, Caregiver		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident care needs are not being met

INVESTIGATION FINDINGS:

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On 11/2/2022 at 10:30AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Estelita Calaguas, Caregiver and explained the reason for the visit. Administrator, Joaquin Cunanan, arrived at 10:55AM.

During the investigation LPA interviewed staff and witness. LPA requested the following documents to be emailed to LPA by the end of business day 11/2/2022: Admission agreement; Identification and emergency contact; Contact for Diablo Valley Foundation; Proposed conservator ship; Physician's reports for 2020 and 2021; Appraisal needs and services plan for 2021, Advance Healthcare Directive and Power of Attorney for Healthcare and Personal care, and L500. LPA obtained facility roster during visit.

Continued on LIC9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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-20210520122215

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 III	FACILITY NUMBER: 075601282
	VISIT DATE: 11/02/2022

NARRATIVE

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Continued from LIC9099.

On the allegation resident care needs are not being met. During interview with S2 it was stated that R1 received bed baths every day. S2 also stated that caregivers did not groom toenails. Toenails had to be done by a podiatrist. Staff was not able to provide documentation that a podiatrist had visited R1. S1 stated the podiatrist was contacted when necessary.

Based on LPAs observations, interviews which were conducted, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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
05/20/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210520122215

FACILITY NAME:	QCARE RESIDENTIAL FACILITY III		FACILITY NUMBER:	075601282
ADMINISTRATOR:	CUNANAN, JOAQUIN		FACILITY TYPE:	740
ADDRESS:	4369 FAIRWOOD DRIVE		TELEPHONE:	(925) 682-0111
CITY:	CONCORD	STATE: CA	ZIP CODE:	94521
CAPACITY:	6	CENSUS: 4	DATE:	11/02/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Estelita Calaguas, Caregiver		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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9

Authorized representatives were not notified of hospitalization

INVESTIGATION FINDINGS:

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2
3
4
5
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7
8
9
10
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12
13

On 11/2/2022 at 10:30AM, Licensing Program Analyst (LPA), L. Hall arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Estelita Calaguas, Caregiver and explained the reason for the visit. Administrator, Joaquin Cunanan, arrived at 10:55AM.

During the investigation LPA interviewed staff and witness. LPA requested the following documents to be emailed to LPA by the end of business day 11/2/2022: Admission agreement; Identification and emergency contact; Contact for Diablo Valley Foundation; Proposed conservator ship; Physician's reports for 2020 and 2021; Appraisal needs and services plan for 2021, and Advance Healthcare Directive and Power of Attorney for Healthcare and Personal care.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

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-20210520122215

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 III	FACILITY NUMBER: 075601282
	VISIT DATE: 11/02/2022

NARRATIVE

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Continued from LIC9099.

On the allegation authorized representatives were not notified of hospitalization. S1 stated that he contacted W1 who was the conservator for R1. S1 also stated he also contacted W2 prior to W1 becoming the conservator. LPA called and spoke with W1 during visit. W1 stated the company was never assigned because R1 had expired. S1 called W2 during visit. LPA interviewed W2 via telephone during visit. W2 stated that she and another neighbor were contacted via telephone when R1 was hospitalized. S1 was not able to provide any incident reports for R1 and stated that he did not report incidents to Community Care Licensing.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20210520122215

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 III	FACILITY NUMBER: 075601282
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/09/2022 Section Cited CCR 87468.1(a)(16)	1 2 3 4 5 6 7	87468.1 (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (16) To receive or reject medical care or other services This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to submit a self-certification that the regulation 87468.1 has been reviewed and administrator will abide by the regulation. Self-certification will be submitted by the POC date.
	8 9 10 11 12 13 14	Based on LPA interviews and record reviews Licensee did not comply with the section cited above in having R1's seen by podiatrist, which poses a potential health and safety risk to persons 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: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5