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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601447
Report Date: 12/09/2021
Date Signed: 12/09/2021 01:58:38 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
02/23/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210223082908
FACILITY NAME:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
075601447
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Ophelia Pedroso, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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9
Resident sustained pressure injuries while in care

Staff left resident in soiled clothing for extended period of time

Facility is not providing activities for resident

Staff is not providing adequate food for resident
INVESTIGATION FINDINGS:
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5
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13
On 12/09/2021 at 11:25AM, Licensing Program Analysts (LPAs), L. Hall and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the above allegations. LPAs met with Ophelia Pedroso, Administrator, and explained the reason for the visit.

During the course of the investigation, LPAs interviewed staff, witnesses, obtained and reviewed documents. It was alleged that staff left Resident 1 (R1) in soiled clothing for extended period of time. Based on that allegation it could have resulted R1 to sustain pressure injuries while in care. W1 stated during interview that after 3 weeks of visiting R1 for a heel pressure wound, W1 conducted a body check and found two (2) new additional pressure wounds at Stage 2.

Continued on LIC9099.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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 6
Control Number 15-AS-20210223082908
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
VISIT DATE: 12/09/2021
NARRATIVE
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Continued from LIC9099.

Staff 1 (S1) stated staff did observe redness on R1. Two (2) witnesses and W1 stated they had observed R1 wet and needing to be changed. LPA reviewed physician’s report, discharge summary, and resident appraisal which indicated R1 required assistance with toileting. Staff 1 (S1) stated during interview that incontinent residents are changed in the morning, lunch, dinner and before bed.

On the allegation facility is not providing activities for resident. LPAs obtained an activity calendar. The calendar indicated that the residents should do daily morning exercises, puzzles, and other games. LPA had visited the facility on several occasions and observed two (2) of the three (3) residents watching television each time. The third resident was in the bedroom. There were not any activities being conducted on any of the visits. S1 stated the residents play dominoes once or twice a month.

On the allegation staff is not providing adequate food for resident. Upon arrival LPAs observed Staff 2 (S2) cooking and residents finishing eating lunch. S2 stated that staff does not follow menu that is posted. LPAs obtained a copy of the menu. Based on LPAs' observation during visit the facility does not maintain a variety of foods. There was not a 2-day supply of perishables and 7 day supply of non-perishables.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC9099D.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
02/23/2021 and conducted by Evaluator Laura Hall
COMPLAINT CONTROL NUMBER: 15-AS-20210223082908

FACILITY NAME:LAFAYETTE RESIDENTIAL CAREFACILITY NUMBER:
075601447
ADMINISTRATOR:OPHELIA PEDROSOFACILITY TYPE:
740
ADDRESS:1300 JUANITA DRIVETELEPHONE:
(925) 945-6833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 3DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Ophelia Pedroso, AdministratorTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff not meeting residents needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 12/09/2021 at 11:25AM, Licensing Program Analysts (LPAs), L. Hall and J. Clancy-Czuleger arrived unannounced to conduct a complaint investigation and to deliver complaint findings for the above allegations. LPAs met with Ophelia Pedroso, Administrator, and explained the reason for the visit.

During the course of the investigation, LPAs interviewed staff, a witness, obtained and reviewed documents. On the allegation staff not meeting resident needs. Interviews with staff and Resident 2 (R2) indicate that residents’ basic services are being met. S1 stated during interview that residents are bathed every other day and are assisted with ADL’s. LPAs observed a total of three (3) residents which appeared to be safe.

Continued on LIC9099C.


Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20210223082908
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
VISIT DATE: 12/09/2021
NARRATIVE
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3
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5
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Continued from LIC9099.

LPAs toured facility including but not limited to bedrooms, kitchen, bathroom, and common areas. LPAs observed facility to be clean, sanitary and in good repair.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.



Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 15-AS-20210223082908
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87468.1(a)(2)
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87468.1 (a) Residents... shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidence by:.
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Administrator agreed to put in place a procedure for implementing body checks for residents and submit a copy to CCLD buy POC date.
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Based on interviews Licensee did not comply with the section cited above in prevention of pressure wounds, which could cause a potential health and safety risk to persons in care.
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Type B
12/16/2021
Section Cited
CCR
87625(b)(3)
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87625 (b) In addition to Section 87611... the licensee shall be responsible for the following:
(3) Ensuring that incontinent residents are kept clean and dry... from incontinence. This requirement was not met as evidence by:
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Administrator agreed to implement a schedule to check residents that are incontinent and submit a copy to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above in keeping resident dry, which could cause a potential health and safety risk to persons in care.
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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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20210223082908
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: LAFAYETTE RESIDENTIAL CARE
FACILITY NUMBER: 075601447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87219(a)
1
2
3
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5
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87219 Planned Activities
(a) Residents shall be encouraged to maintain and develop... independent living through participation in planned activities. This requirement was not met as evidence by:
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Administrator agreed to review the regulation 87219 and submit an updated activity scheduled to CCLD by POC date.
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Based on interviews the Licensee did not comply with the section cited above by conducting activities with residents, which poses a potential health and safety risk to persons in care.
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Type B
12/16/2021
Section Cited
CCR
87555(b)(26)
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87555 (b)The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained... This requirement was not met as evidence by:

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Administrator agreed to purchase a supply of food and submit a copy of the receipt and photos to CCLD by POC date.
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Based on LPAs observation, Licensee did not comply with the section cited above, which poses a potential health and safety risk to persons in care.
8
9
10
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13
14
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: Laura HallTELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6