075601406-8-10-2023-15-AS-YFLS-CUZN82-20230824101337

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601406
Report Date: 08/10/2023
Date Signed: 08/10/2023 12:29:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
04/01/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220401154732

FACILITY NAME:	LA CASA VERDE		FACILITY NUMBER:	075601406
ADMINISTRATOR:	ALCANTARA, LEONARDO		FACILITY TYPE:	740
ADDRESS:	1405 CAMINO VERDE		TELEPHONE:	(925) 285-5078
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	6	CENSUS: 2	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Leonardo Alcantara, Administrator		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Resident was over medicated while in care.
Facility does not have awake staff at night.
Facility did not fulfill reporting requirements.
Facility did not seek resident timely medical attention.
Facility did not ensure that resident received sufficient nourishment while in care.
Resident's fee increase was not clearly specified.
Facility failed to issue a proper refund.

INVESTIGATION FINDINGS:

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On 8/10/2023 at 9:45 AM, Associate Governmental Program Analyst (AGPA) L. Francisco and Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct complaint investigation and deliver findings for the above allegations. AGPA and LPA met with Administrator, Leonardo Alcantara and explained the purpose of the visit.

During the complaint investigation, AGPA L. Francisco obtained information, reviewed records, collected documents, interviewed staff and attempted to interview residents.

Allegation: Resident was over medicated while in care.
However, AGPA observed medications listed on the centrally stored medication log and medication administration record (MAR) matched the medication order's provided by R1's physician. LPA observed staff initialled MAR according to the prescription instruction.

***REPORT CONTINUED ON 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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 3

Control Number 15-AS-20220401154732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CASA VERDE	FACILITY NUMBER: 075601406
	VISIT DATE: 08/10/2023

NARRATIVE

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Allegation: Facility does not have awake staff at night.
Based on interviews with S1 and S2, they respond to residents when residents call for help. According to S2, S2 wakes up every hour and checks on the residents. AGPA and LPA attempted to interview two residents (2) but were unable to obtain additional information.

Allegation: Facility did not fulfill reporting requirements.
Based on information obtained from complainant, R1 fell out of her wheelchair. However, S1 and S2 denied of the incident. AGPA reviewed discharged notes from the hospital and it did not indicate that R1 fell out of her wheel chair. Due to conflicting information, AGPA was unable to prove or disprove allegation.

Allegation: Facility did not seek resident timely medical attention.
Based on record review of staff daily notes, on 3/14/23, S2 observed R1 had phlegm and was congested. S2 notified R1's responsible party and suggested R1 is to be seen by the doctor. According to the staff notes, R1 was not exhibiting shortness of breath. R1 was admitted to the hospital by R1's responsible party

Allegation: Facility did not ensure that resident received sufficient nourishment while in care.
Based on information obtained by complainant, due to R1 being over medicated from drugs, R1 was not eating. AGPA reviewed appraisal and physician's report and both records indicated R1 is able to feed herself. However, S1 and S2 stated R1 needed assistance. AGPA obtained a copy of an order from R1's speech therapist that puree diet with honey thick liquids to be initiated on 3/2/22.

Resident's fee increase was not clearly specified.
Based on record review, AGPA obtained a copy of the notification and observed that R1 was given a 60 day notice of the increase due to change in condition. However, R1 was not charged of the new rate because R1 had moved out of the facility.

***REPORT CONTINUES ON 9099C***

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220401154732

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: LA CASA VERDE	FACILITY NUMBER: 075601406
	VISIT DATE: 08/10/2023

NARRATIVE

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Facility failed to issue a proper refund.
Based on record review of Admission Agreement, residents/responsible parties are to provide a 30-day notice or rates will continue. AGPA discovered when R1 was admitted to the hospital by R1's responsible party on 3/14/23, R1 never returned to the facility and facility was not provided a 30-day notice.

Although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Administrator and a copy of report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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