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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601508
Report Date: 09/20/2021
Date Signed: 09/20/2021 10:53:46 AM

Substantiated


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
01/24/2020 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20200124133241
FACILITY NAME:CORTONA PARKFACILITY NUMBER:
075601508
ADMINISTRATOR:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 102DATE:
09/20/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Agustin Samaniego, Executive DirectorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Personal Rights - Staff improperly transferred resident resulting in multiple fractures.
Personal Rights - Facility failed to seek medical treatment in a timely manner.
INVESTIGATION FINDINGS:
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On 9/20/2021 at 9:30am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver complaint findings. LPA met with Executive Director, Agustin Samaniego and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: R1’s admission agreement, physician’s report, care plan, medication log, incident report, photos of resident, discharge notes, corrective action for staff and lift manual were obtained.


REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 5
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
01/24/2020 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20200124133241

FACILITY NAME:CORTONA PARKFACILITY NUMBER:
075601508
ADMINISTRATOR:AGUSTIN SAMANIEGOFACILITY TYPE:
740
ADDRESS:150 CORTONA WAYTELEPHONE:
(925) 240-0733
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:150CENSUS: 102DATE:
09/20/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Agustin Samaniego, Executive DirectorTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility failed to issue a refund in a timely manner.
Facility illegally evicted resident.
INVESTIGATION FINDINGS:
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On 9/20/2021 at 9:30am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Agustin Samaniego and explained the purpose of the visit.

During course of the investigation, the Department conducted interviews with facility staff, witnesses and complainant. Documents including but not limited to: R1’s admission agreement, physician’s report, care plan, medication log, incident report, photos of resident, discharge notes, corrective action for staff and lift manual were obtained.


REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
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 5
Control Number 15-AS-20200124133241
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: CORTONA PARK
FACILITY NUMBER: 075601508
VISIT DATE: 09/20/2021
NARRATIVE
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Based on record review, resident’s belongings were removed from the facility on 11/30/2019 and a refund was issued on 12/18/2019. LPA observed no specific time frame for refunds in the Admission Agreement once personal properties are removed by resident. Therefore, LPA was unable to determine whether the refund was issued in a timely manner.

Based on interview with S5, R1 was evaluated at the skilled nursing facility due to R1’s change in condition. S4 determined R1 was bed bound and would require total care. S4 stated resident was able to return to facility if resident was admitted to hospice or to be provided one on one care. However, R1’s responsible party contacted S4 one week later and refused.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20200124133241
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: CORTONA PARK
FACILITY NUMBER: 075601508
VISIT DATE: 09/20/2021
NARRATIVE
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The Department investigated staff improperly transferred resident resulting in multiple fracture and staff failed to seek medical treatment in a timely manner. Based on record review, corrective actions were issued to S1, S2 and S3 on 10/28/2019 for lifting R1 from the floor while in pain. Discharged notes from 10/31/2019 indicates resident sustained a fracture of right distal femur.

Interview with S4 revealed staff has not yet called 911 when S4 arrived at R1’s apartment. When S4 was asked how much time has passed during the interview, S4 stated S4 did not know the exact time, but “it had to been awhile". S4 then contacted 911.

Based on the information obtained, interviews and record reviews that the Department obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations are SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

A $500 civil penalty is assessed for violation that resulted in a serious injury. Additional civil penalties and/or Administrative Action may occur.

Exit interview conducted. A copy of report, appeal rights and civil penalties is provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20200124133241
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: CORTONA PARK
FACILITY NUMBER: 075601508
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/21/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights
87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement was not met as evidenced by:
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By POC date, Administrator agrees review regulations and submit a self-certification letter to CCL.
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Based on record review and interviews, Licensee did not comply with regulations above. Record review indicates that staff were issued a corrective actions for lifting resident from the floor while in pain which poses an immediate personal rights and health and safety to residents in care.
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An immediate $500 Civil Penalty is being assessed.
Request Denied
Type A
09/21/2021
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care
87465(g) (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including...

This requirement was not met as evidenced by:
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By POC date, Administrator agrees to review regulation and conduct training with staff and submit a self-certification letter to CCL.
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Based on record review and interviews, Licensee did not comply with the regulation above. It was confirmed by multiple staff that staff did not immediately contact 911 which poses a health and safety risk to residents 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: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5