075601431-5-1-2024-15-AS-BFOG-D5HTYR-20240522150910

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601431
Report Date: 05/01/2024
Date Signed: 05/01/2024 12:42:01 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
04/29/2024 and conducted by Evaluator Lori Alexander-Washington

COMPLAINT CONTROL NUMBER: 15-AS-20240429125748

FACILITY NAME:	WALNUT CREEK WILLOWS		FACILITY NUMBER:	075601431
ADMINISTRATOR:	GOCO, MARISOL		FACILITY TYPE:	740
ADDRESS:	2015 MT. DIABLO BLVD.		TELEPHONE:	(925) 256-8708
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	72	CENSUS: 43	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Rizza Madlangbayan, Administrative Assistant		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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1. Staff installed bed rails on resident's bed without proper authorization

INVESTIGATION FINDINGS:

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On 05/01/2024, at 9:15 am, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct initial 10-day complaint visit for the above allegation. LPA met with Rizza Madlangbayan and explained the reason for the visit. Licensee/Administrator, Elizabeth "Beth" Cortes, was phoned. Beth arrived approximately an hour later.

The following documents were obtained:
1. Resident Registry
2. Physician's Report (LIC 602A) for R1
3. Resident Appraisal (LIC603A)
4. Resident Plan of Care (Dated 04/16/24)
5. Appraisal Needs and Services Plan (LIC625 dated 04/16/24)
6. Physician's Orders
7. Appointment of Representative (MC306)
8. SNF Transition Checklist

LIC9099-C Continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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-20240429125748

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: WALNUT CREEK WILLOWS	FACILITY NUMBER: 075601431
	VISIT DATE: 05/01/2024

NARRATIVE

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Allegation: Staff installed bed rails on resident's bed without proper authorization
Substantiated.

On 05/01/24 LPA spoke to RP who stated that R1 stated to them that they felt like they were in "a cage." RP further explained that R1 stated that the bed rails on the bed made them feel like they were in a cage. RP stated that S1 said that R1 was a fall risk and that the bed rail was for safety. RP stated that R1 did not have a doctor's order for a bed rail, but the staff removed the bed rail while RP was at the facility on 04/22/24. LPA interviewed R1 and R1 stated that the bed rail was on the bed initially but the Staff removed the bed rail. LPA reviewed R1's Physician Report and the report did not have any information that reflected the use of a bed rail for mobility support. LPA observed that the bed rail was removed on R1's bed. LPA advised S1 that bed rail for postural and mobility support requires a doctor's order. Based on information that S1 admitted that there was a bed rail on R1's bed the allegation is substantiated.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240429125748

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: WALNUT CREEK WILLOWS	FACILITY NUMBER: 075601431
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 05/02/2024 Section Cited CCR 87608(a)(3)	1 2 3 4 5 6 7	(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.	1 2 3 4 5 6 7	Administrator removed bed rail. Deficiency cleared during visit.
	8 9 10 11 12 13 14	Based on interview, the licensee did not comply with the section cited above in by not having a written order from a physician for a bed rail for R1 which poses a potential health, safety or 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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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