075601411-10-20-2021-15-AS-KHOS-C8DJM4-20211102070942

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601411
Report Date: 10/20/2021
Date Signed: 10/20/2021 05:15:21 PM

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
07/02/2020 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20200702133152

FACILITY NAME:	MUIR CREEK SENIOR HOME		FACILITY NUMBER:	075601411
ADMINISTRATOR:	CARBONEL, LELIA C.		FACILITY TYPE:	740
ADDRESS:	1066 MUIR CREEK DRIVE		TELEPHONE:	(925) 427-7049
CITY:	PITTSBURG	STATE: CA	ZIP CODE:	94565
CAPACITY:	6	CENSUS: 5	DATE:	10/20/2021
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Lelia Carbonel, Administrator		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Staff mishandles resident while in care

Staff mishandling resident's medication

Staff failed to provide a comfortable temperature for resident

INVESTIGATION FINDINGS:

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On 10/20/2021 at 02:10PM, Licensing Program Analyst (LPA) L. Hall arrived unannounced to conduct complaint investigation and deliver complaint findings for the above allegations. LPA met with Lelia Carbonel, Administrator, and explained the reason for the visit.

During the course of the investigation, LPA conducted interviews with two (2) of three (3) staff, four (4) of five (5) residents, Reporting Party (RP), wintess, obtained and reviewed documents. Interviews with staff and residents indicated that staff does not mishandle residents while in care. Staff or residents have not seen any staff mishandle residents.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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-20200702133152

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: MUIR CREEK SENIOR HOME	FACILITY NUMBER: 075601411
	VISIT DATE: 10/20/2021

NARRATIVE

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Continued from LIC9099.

On the allegation staff mishandling resident's medication. LPA reviewed physician's reports and documents from hospice agency which indicated R1's needs thickened liquid when swallowing foods and medication.

On the allegation staff failed to provide a comfortable temperature for resident. During investigation LPA observed facility's temperature at 75 degrees F. Interviews with residents stated the temperature is always comfortable and if not staff will adjust temperature. Document review indicated that R1's room did get hot and in order to cool the room down the ceiling fan was turned on and an additional fan is used to blow the hot air out of the room.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conduct and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC9099 (FAS) - (06/04)

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