075601332-12-15-2022-15-AS-BFOG-CP5SVU-20230217131319

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601332
Report Date: 12/15/2022
Date Signed: 12/15/2022 08:14:10 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
01/15/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210115122146

FACILITY NAME:	BOYD SENIOR CARE HOME		FACILITY NUMBER:	075601332
ADMINISTRATOR:	PERDIGUERRA, LILIA		FACILITY TYPE:	740
ADDRESS:	345 BOYD ROAD		TELEPHONE:	(925) 256-6500
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS:	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Lilia Perdiguerra/Licensee-Administrator		TIME COMPLETED:	08:15 PM

ALLEGATION(S):

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Staff spoke inappropriately to a care provider in the resident’s presence.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegation and close the complaint. LPA met with Lilia Perdiguerra, licensee-administrator.

It was alleged that during one of Home Health (HH) visit, and staff (HH1) tried to educate the staff on how to care for resident (R1), the licensee spoke inappropriately at HH1 in the resident's presence.

During the course of investigation, LPA interviewed the licensee and 2 residents. The licensee stated during one of HH1's visits, HH1 asked her where is the sliding board. The sliding board is use to help in transferring R1 from the bed to wheelchair and vice versa. Licensee stated she told HH1 that HH1 didn't leave the board in the facility. Licensee indicated she lost her patience when HH1 insisted she left ithe board, and the way HH1 spoke to her. Two of the residents indicated they heard the licensee and HH!'s argument.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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 8

Control Number 15-AS-20210115122146

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: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
	VISIT DATE: 12/15/2022

NARRATIVE

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

Deficiency is cited from Title 22 California Code of Regulations and listed on 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 and proof of correction were discussed with the licensee.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 15-AS-20210115122146

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: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/15/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/22/2022 Section Cited HSC 1569.269(a)(1)	1 2 3 4 5 6 7	§1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Licensee to read the Regulations and ensure it's followed. Self-certification to be submitted by 12/22/2022,
	8 9 10 11 12 13 14	-This requirement is not met as evidenced by: -Based on interviews, the licensee did not comply with the section above when licensee had an argurment with HH1 which posed potential personal rights 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
01/15/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210115122146

FACILITY NAME:	BOYD SENIOR CARE HOME		FACILITY NUMBER:	075601332
ADMINISTRATOR:	PERDIGUERRA, LILIA		FACILITY TYPE:	740
ADDRESS:	345 BOYD ROAD		TELEPHONE:	(925) 256-6500
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS:	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Lilia Perdiguerra/Licensee-Administrator		TIME COMPLETED:	08:15 PM

ALLEGATION(S):

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-Facility is not meeting the resident's (R1) needs as identified in the appraisal.

-Staff are not meeting the resident's (R1)hygiene needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Lilia Perdiguerra, licensee-administrator.

During the course of investigation, LPA obtained copies of residents' including but not limited to the folowihg documents: LIC601 Identification abd Emergency Contact information; Admission Agreement; LIC602A Physician's Report; Appraisal Needs and Services Plan; medical records; Home Health records and Visit/Progress Notes. LPA conducted interviews,

Allegation: Facility not meeting resident's (R1) needs as identified in the appraisal.
It was alleged that the facility is not following the proper turning and repositioning of R1, It was further alleged that R1 is not moved enough and when moved, staff S1 would not move R1 properly and instead lift and plop R1 on the chair,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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 8

Control Number 15-AS-20210115122146

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: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
	VISIT DATE: 12/15/2022

NARRATIVE

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LPA interviewed Home Health staff (HH1), licensee, staff (S1 and S2) and resident R1. HH1 stated R1's Care Plan is to transfer R1 from bed to wheelchair and vice versa, and the facility is not following the Care Plan by not using the sliding board. HH1 also indicated R1 is not repositioned properly. Licensee, S1 and S2 indicated they repositioned R1 consistent with the Care Plan. S1 indicated that at times, he used the sliding board to transfer R1 but R1 would scream so the staff adjusted to R1's comfort level by at times lifting him up when transferring instead of using the sliding board.

Allegation: Staff are not meeting the resident's (R1) hygiene needs.
it was alleged that the licensee failed to keep R1's foley catheter clean and the catheter bag on the dirty/dusty floor and R1 not wearing socks.

During the course of investigation, LPA conducted inspections and didn't observed the facility dirty, LPA interviewed Home Health staff (HH! and HHO), staff (S1) and licensee. HH1 indicated she observed R1's catheter bag on the dirty floor and R1 not wearing socks, HHO stated she has not observed the facility dirty nor residents raggedy. S1 stated he has not observed R1's catheter bag on the floor. Licensee indicated that R1's catheter bag has a hook to attach to the R1's hospital bed; however, there were times that R1 moves a lot and the bag will fall on the floor. Home Health has given her instruction to place a basin on the floor where the bag will fall in the event it's unhooked. Records obtained showed R1 is also seen by Home Health of catheter care.

Based on the information gathered, both 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.

No deficiency cited.

Exit interview conducted and copy of this report provided,

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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
01/15/2021 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20210115122146

FACILITY NAME:	BOYD SENIOR CARE HOME		FACILITY NUMBER:	075601332
ADMINISTRATOR:	PERDIGUERRA, LILIA		FACILITY TYPE:	740
ADDRESS:	345 BOYD ROAD		TELEPHONE:	(925) 256-6500
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS:	DATE:	12/15/2022
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Lilia Perdiguerra/Licensee-Administrator		TIME COMPLETED:	08:15 PM

ALLEGATION(S):

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-Resident (R1) sustained a stage 3 pressure injury while in care.
-Facility failed to ensure insertion & irrigation of catheter is performed by an appropriately skilled professional.
-Resident is not allowed to wear his own clothing.
-Facility floors are dirty.
-Facility staff do not have required and appropriate training.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Delmundo arrived unannounced to continue the investigation of the above allegations and close the complaint. LPA met with Lilia Perdiguerra, licensee-administrator.

During the course of investigation, LPA conducted inspection and interviews. LPA also obtained copies of residents' including but not limited to the folowihg documents: LIC601 Identification abd Emergency Contact information; Admission Agreement; LIC602A Physician's Report; Appraisal Needs and Services Plan; medical records; Home Health records and Visit/Progress Notes.

.....continued on 9099C (page 2)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

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

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 15-AS-20210115122146

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: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
	VISIT DATE: 12/15/2022

NARRATIVE

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Page 2

Allegation: Resident (R1) sustained a stage 3 pressure injury while in care.
LPA interviewed Home Health (HH1) who stated R1 has already stage 3 pressure injury when admitted to the facillty. Review of R1's records revealed R1 was seen by Home Health upon admission to the facilty for wound and catheter care, Records also showed R1 has stage 3 pressure injury when R1 moved-in.

Allegation: Facility failed to ensure insertion & irrigation of R1's catheter is performed by an appropriately skilled professional
It was alleged that licensee is a nurse; however, licensee fails to keep the foley catheter clean which has led to infections.

Licensee stated she not a nurse but a retired med tech. Licensee and S1 atated they were empty R1's catheter. The irrigation and changing of the foley catheter were done by Home Health. Review of R1's records showed R1 has Home Health for catheter care when R1 moved in.

Allegation: Resident is not allowed to wear his own clothing.
It was alleged that most of the time resident (R1) is not allowed to wear his own clothing because the staff find it easier to care for R1 in gowns even though R1 prefers to wear his clothes.

During the course of investigation, LPA conducted inspection and observed R1 wearing hospital gown. LPA interviewed the licensee and S1 who both stated that it's R1's choice to wear hospital gown. Licensee stated that R1 was stiff and would not want to wear his clothes. R1 stated that HH1 wants R1 to wear pants and shirt. R1 indicated he does want to get dressed each day and take off the dress and prefers to wear scrub. R1 does not want to wear socks.

Allegation:Facility floors are dirty.
LPA condiucted inspections and didn't observe the facility and flooring dirty, LPA interviewed Home Health staff (HHO) who stated she has not observed the facility on any of her visits,

....continued on 9099C (page 3)

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 15-AS-20210115122146

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: BOYD SENIOR CARE HOME	FACILITY NUMBER: 075601332
	VISIT DATE: 12/15/2022

NARRATIVE

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Page 3

Allegation: Facility staff do not have required and appropriate training.
It was alleged that licensee not wearing gloves changing the foley catheter, It was further alleged went to the hospital twice for sepsis and that both incidents were due to improper handling of the foley catheter.

Review of R1's records showed R1 was seen by Home Health for catheter care, LPA interviewed the licensee and S1 who both stated they only empty the bag and use gloves and mask when doing so, Review of records showed R1 has Catheter Care Plan and staff have the required training on file.

Based on all the information obtained the allegations were unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.

No deficiency cited,

Exit interview conducted and copy of this report provided,

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia Delmundo	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2022

LIC9099 (FAS) - (06/04)

Page: 8 of 8