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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601332
Report Date: 05/08/2025
Date Signed: 05/08/2025 08:45:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
04/29/2025 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250429090737
FACILITY NAME:BOYD SENIOR CARE HOMEFACILITY NUMBER:
075601332
ADMINISTRATOR:PEDIGUERRA, JERRYFACILITY TYPE:
740
ADDRESS:345 BOYD ROADTELEPHONE:
(925) 256-6500
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 5DATE:
05/08/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jerry Pediguerra, Administrator TIME COMPLETED:
07:30 PM
ALLEGATION(S):
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Staff mismanaged resident's medication
Staff threatened resident in care
Staff did not properly maintain resident records
INVESTIGATION FINDINGS:
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On 05/08/2025 at 2:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegations. LPA met with Caregiver, Lilia Pediguerra and explained the reason for the visit. Mrs. Pediguerra phoned Administrator, Jerry Pediguerra, to inform. Jerry arrived shortly after.

LPA obtained and reviewed documents: Medication Lists and Doctor's Orders for Residents (R) R1-R5.



LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
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-20250429090737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BOYD SENIOR CARE HOME
FACILITY NUMBER: 075601332
VISIT DATE: 05/08/2025
NARRATIVE
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LIC9099-C

Allegation: Staff mismanaged resident's medication
Finding: Substantiated

On 05/07/2025 LPA interviewed Witness (W) W1, W1 stated that R1 was not being administered prescription medication according to Doctor's orders.

On 05/08/2025 LPA interviewed Staff (S) S1. LPA reviewed R1-R5 medication list and observed discrepancies with R2, R3, R4 and R5's medication lists and what was centrally stored medication. S1 stated that they get information of the medications from the resident's authorized representatives. LPA reviewed R1's medication list which was a new care plan as of 05/07/2025. S1 stated that R1's new medications hadn't delivered yet.


Allegation: Staff threatened resident in care
Finding: Substantiated

On 05/07/2025 LPA interviewed Witness (W) W1. W1 stated that caregiver(s) threatened eviction of R1 due to behaviors of overnight insomnia and restless activity.

On 05/08/2025 LPA interviewed S1 that stated it has been discussed because R1's behavior with getting up in the night, wandering and disrupting the other residents.
LPA reviewed R1's physician's report which indicates a diagnosis of dementia. LPA asked S1 was there a change of condition since R1 was admitted and there hasn't been any changes.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20250429090737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: BOYD SENIOR CARE HOME
FACILITY NUMBER: 075601332
VISIT DATE: 05/08/2025
NARRATIVE
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LIC9099-C Continued...

Allegation: Staff did not properly maintain resident records
Finding: Substantiated

On 05/07/2025 LPA interviewed Witness (W) W1. W1 stated that administered medications were not being documented according to medication list.

On 05/08/2025 LPA interviewed Staff (S) S1. LPA requested to review the medication records for administered medication for all residents from January thru May 2025. S1 stated that they didn't have records from January and only had record for current month.

LPA reviewed the Medication Administration Record (MAR) for May and observed that residents' medication lists did not correlate with the MAR.

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






SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20250429090737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOYD SENIOR CARE HOME
FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2025
Section Cited
CCR
87465(d)(3)
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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
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Administrator agreed to complete 2hr (minimum) training for all staff with an CCLD approved vendor for Medication training with records and documenting. Submit certificates to CCLD by POC due date.
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Based on observation, record review and interview, the licensee did not comply with the section cited above in by ensuring R1's thru R5's MAR were complete which poses a potential health and safety risk to persons in care.
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Type B
06/05/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care...that meet their individual needs and are delivered by staff...competency to meet their needs.
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Administrator agreed to complete 2hr (minimum) training for all staff with an approved CCLD vendor for Medication training with prescription and non-prescription orders. Submit certificates to CCLD by POC due date.
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Based on observation, record review and interview, the licensee did not comply with the section cited above in by ensuring R1 thru R5 medications were administered according to doctor's orders including but not limited to presciptions and non-prescriptions which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20250429090737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: BOYD SENIOR CARE HOME
FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/05/2025
Section Cited
CCR
87705(b)(1)(A)
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87705 Care of Persons with Dementia
(b) Licensees shall be responsible for the following:(1) Ensuring staff receive the following training...
(A) Dementia care, including, but not limited to, knowledge about ...behavioral challenges....

This requirement is not met as evidenced by:
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Administrator agreed to complete 2hr (minimum) training for all staff with an CCLD approved vendor for Dementia Care with a focus on challenging behaviors. Submit certificates to CCLD by POC due date.
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Based on interview, the licensee did not comply with the section cited above in by handling dementia care residents that may have including but not limited behavioral challenges that may be difficult for staff to handle. Staff caregiver stated possible eviction of R1 which poses a potential health, safety risk and personal rights to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5