075601503-1-12-2023-15-AS-KHOS-CP2MNF-20230214084529

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601503
Report Date: 01/12/2023
Date Signed: 01/12/2023 01:41:14 PM

Unsubstantiated

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
11/09/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20211109140910

FACILITY NAME:	MAGNOLIA GARDEN AT DANVILLE		FACILITY NUMBER:	075601503
ADMINISTRATOR:	OLIVA, JOSEPH ANTHONY		FACILITY TYPE:	740
ADDRESS:	205 EL PINTO ROAD		TELEPHONE:	(925) 820-9801
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	36	CENSUS: 19	DATE:	01/12/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Heidi Yrreverra, Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff handled resident in a rough manner
Staff did not notify authorized representative of residents fall

INVESTIGATION FINDINGS:

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On 1/12/2023 at 1:30 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Administrator, Heidi Yrreverra and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, collected documents, reviewed records, and interviewed 2 staff and 4 residents. It was alleged staff handled resident in a rough manner. Based on interview with S2 and record review, Resident 1 (R1) was found on the floor alongside R1's bed on 11/4/2021 at 1:00 AM. S2 assessed and assisted R1 back to bed per R1's request. According to S2, there was no visible injury and R1 did not express of any pain. No forthcoming information obtained from R1.4 of 4 residents denied being handled in a rough manner by staff.

REPORT CONTINUED ON LIC 9099-C

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: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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-20211109140910

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: MAGNOLIA GARDEN AT DANVILLE	FACILITY NUMBER: 075601503
	VISIT DATE: 01/12/2023

NARRATIVE

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It was alleged staff did not notify authorized representative of residents fall. Based on information obtained by complainant, R1's Power of Attorney (POA) was not notified of the incident. No forthcoming information obtained from R1 and F1. Therefore, LPA was unable to confirm if R1 has a POA. Interview with S1 revealed that facility was not provided of any documentation upon admission so S1 stated that F2 was notified because F2 lived nearby. LPA reviewed records and LPA observed F2 is listed as one of the emergency contact person and a text was sent to F2 of the incident that occurred on 11/4/2021.

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 this report of provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

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