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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601406
Report Date: 08/13/2021
Date Signed: 08/13/2021 11:25:08 AM



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
04/01/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210401092906
FACILITY NAME:LA CASA VERDEFACILITY NUMBER:
075601406
ADMINISTRATOR:ALCANTARA, LEONARDOFACILITY TYPE:
740
ADDRESS:1405 CAMINO VERDETELEPHONE:
(925) 285-5078
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:6CENSUS: 0DATE:
08/13/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Leonardo Alcantara, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Personal Rights - Resident's care needs were not met resulting in hospitalization.
INVESTIGATION FINDINGS:
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On 8/13/2021 at 10:30am, Licensing Program Analyst (LPA) L. Francisco arrived at the facility to deliver findings on the above allegation and met with Administrator. LPA explained to Administrator the purpose of visit.

The Department has investigated the above allegation. On 3/9/2021 while R1 was on a Facetime call with sister, R1’s sister observed R1 experiencing slurring words. R1’s sister called her brother to transport R1 to Kaiser Walnut Creek. Hospital records show that R1 reported a “dead leg” feeling for the past few weeks and was under observation for a possible stroke when she went into shock for unspecified reason on 3/10/2021. R1 had low blood pressure and became hypothermic with a temperature of 94.6F. R1 was transferred to the intensive care unit (ICU) and found to have urinary tract retention and a foley catheter was placed on 3/12/2021.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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-20210401092906
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 CASA VERDE
FACILITY NUMBER: 075601406
VISIT DATE: 08/13/2021
NARRATIVE
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Emergency Department Records indicate R1’s diagnoses are Transient Cerebral Ischemia (TIA) and Right Foot Contusion.

During interview, Staff 1 (S1) denied hearing R1 slur her words and was only concerned about R1 falling more often. S1 stated that R1's family is responsible in taking R1 to the doctor. S1 also stated that R1 has not seen a doctor since moving to the facility on January 31, 2019.

Based on the Department's 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 is being cited on the attached LIC 9099D.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210401092906
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 CASA VERDE
FACILITY NUMBER: 075601406
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2021
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs....... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
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Administrator agrees to review regulation and register for training with outside vendor. Administrator will submit a copy of self-certication letter and registration confirmation for training to CCL by POC date
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This requirement is not met as evidenced by: Based on interviews and records review, staff failed to properly observe R1 resulting in R1's hospitalization( ICU) for possible stroke, low blood pressure, hypothermia, urinary retention which poses an immediate health and safety risks to resident in care.
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A $500.00 civil penalty is assessed.
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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.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
04/01/2021 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210401092906

FACILITY NAME:LA CASA VERDEFACILITY NUMBER:
075601406
ADMINISTRATOR:ALCANTARA, LEONARDOFACILITY TYPE:
740
ADDRESS:1405 CAMINO VERDETELEPHONE:
(925) 285-5078
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:6CENSUS: 0DATE:
08/13/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Leonardo Alcantara, AdministratorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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9
Staff deprived resident of linens
Resident's toileting needs were not met
INVESTIGATION FINDINGS:
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On 8/13/2021 at 10:30am, Licensing Program Analyst (LPA) L. Francisco arrived at the facility to deliver findings on the above allegations and met with Administrator. LPA explained to Administrator the purpose of visit.

1. Staff deprived resident of linens
On 4/3/2021, LPA Praveen Singh conducted 10-day investigation. On May 19, 2021, LPA Luisa Fontanilla conducted interviews and televisit with Administrator and observed facility has sufficient supply of linens. Both Administrator and S1 state that facility provides residents with linens unless residents prefer to use their own supply. Administrator states facility provided R1 with all the linens she needed while at the facility.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
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 5
Control Number 15-AS-20210401092906
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 CASA VERDE
FACILITY NUMBER: 075601406
VISIT DATE: 08/13/2021
NARRATIVE
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2. Resident's toileting needs were not met
On May 19, 2021, LPA Luisa Fontanilla interviewed Staff 1. S1 is the primary caregiver for R1. S1 states that R1 had a schedule to address incontinence needs. S1 states R1 gets reminded and escorted to go to the bathroom every two hours or as needed during the day until 1am. After 1am, the next bathroom reminder/escort is at 7am. In one of the photos obtained during investigation, a sign indicating bathroom schedule was observed on R1’s door.

Based on interviews and observations, the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5