075601290-7-21-2022-15-AS-BFOG-CKLSLJ-20221027135822

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601290
Report Date: 07/21/2022
Date Signed: 07/21/2022 03:01:05 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
06/22/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20200622161816

FACILITY NAME:	LA ORINDA CARE HOME		FACILITY NUMBER:	075601290
ADMINISTRATOR:	WONG, RONALD G.		FACILITY TYPE:	740
ADDRESS:	2180 LA ORINDA PLACE		TELEPHONE:	(925) 798-3570
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	6	CENSUS: 4	DATE:	07/21/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Edith Namoro, Staff Ronald Wong, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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On 07/21/22 at 1PM, , Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of the above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Resident sustained pressure injuries while in care
Investigation Finding: SUBSTANTIATED
During investigation records were reviewed and the Administrator, S1 & W1 were interviewed. It was found that R1 was admitted to the facility on 5/1/2019. There was a previous history of a pressure wound that was healed by the time of admission and a home health nurse reported to the facility during the first 2 weeks to train caregivers with R1s ADL and equipment assistance. Care staff reported that they assisted R1 with bathing and changes of incontinent wear on a daily basis, noting that blistering began approximately 3 months after admission and that the Administrator had been informed.
Continued on next page, LIC 9099-C

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: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

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-20200622161816

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: LA ORINDA CARE HOME	FACILITY NUMBER: 075601290
	VISIT DATE: 07/21/2022

NARRATIVE

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W1 reported learning from staff in February 2020 that R1 may have wounds. W1 contacted the PCP, who in turn had a home health nurse evaluate R1 at the facility. On 2/24/20 the home health nurse instructed staff to contact 911. Per hospital records, R1 presented to the ER in an altered state of consciousness and was diagnosed with Hypernatremia; it was found at that time that R1 had an unstageable pressure ulcer and other stage 2 pressure wounds.

This department has investigated the complaint alleging that resident sustained pressure injuries while in care, and per observations, interviews and records reviews finds that the facility failed to provide adequate care and supervision, resulting in R1 sustaining an unstageable wound injury requiring hospitalization. Therefore, the preponderance of evidence standard has been met, and the allegation is found to be substantiated.

An immediate civil penalty of $500 is assessed.

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: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200622161816

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: LA ORINDA CARE HOME	FACILITY NUMBER: 075601290
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/15/2022 Section Cited HSC 1569.269(a)(10)	1 2 3 4 5 6 7	(a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect…and physical abuse.	1 2 3 4 5 6 7	By POC due date, Administrator agrees to submit to CCLD a copy of certification that all staff, including Administrator, have been trained by a CDSS-approved vendor in Care & Supervision, and Personal Rights.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: the facility reported bathing and changing resident daily, yet failed to respond to the development of an unstageable, and other, pressure wounds, which is a threat to the health and safety of persons in care.	8 9 10 11 12 13 14	Immediate civil penalty of $500 assessed during visit.
	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: 07/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2022

LIC9099 (FAS) - (06/04)

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