075601536-9-4-2020-15-AS-HHUL-BTSNLL-20200925103341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601536
Report Date: 09/04/2020
Date Signed: 09/04/2020 07:45:48 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
03/25/2020 and conducted by Evaluator Rolanda Pitcher

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200325084209

FACILITY NAME:	CARNELIAN I		FACILITY NUMBER:	075601536
ADMINISTRATOR:	GRUTAS, KATHERINE		FACILITY TYPE:	740
ADDRESS:	2380 WARREN ROAD		TELEPHONE:	(925) 938-0200
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94595
CAPACITY:	15	CENSUS: 15	DATE:	09/04/2020
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Katherine Grutas		TIME COMPLETED:	07:00 PM

ALLEGATION(S):

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Staff did not notify resident authorized representative of change in health conditions immediately

INVESTIGATION FINDINGS:

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Licensing Program Analyst, (LPA) Rolanda Pitcher conducted an investigation regarding the above allegation. Due to the present shelter in place order by the Governor, the notification of the complaint was addressed over the phone via a tele-visit conference call on 4/6/2020.

During the course of this investigation, LPA Pitcher found no conclusive evidence to support the facility failed to notify the resident responsible representative a change in Resident (R1) health in a timely manner. LPA substantiated between the hour of 8:00 - 8:30 am (R1) physician was informed R1 appeared to have a cough. However, no evidence was found to support the resident physician advised staff to keep the resident on bed rest on the date of 12/17/19.

LPA obtained a copy of R1 records; admission agreement, personal property log, physician report, pre-placement appraisal, functional capability assessment, progress notes, 12/17/19 thru 12/18/19 and a copy of R1 death certificate.

LPA was provided documentation that R1 temperature was taken during physician. R1 temperature was recorded during the call 94.5 degrees and later in the day, 96.1 degrees.

Based on the interview conducted with S1 an attempt was made the morning (RP) Responsible Representative arrived to the community to pick up R1 for a previously scheduled appointment. S1 reports in a haste to leave with R1 refuse to converse at that time.

Unsubstantiated

Estimated Days of Completion: 30

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020

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-20200325084209

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: CARNELIAN I	FACILITY NUMBER: 075601536
	VISIT DATE: 09/04/2020

NARRATIVE

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S1 stated the front desk did received a call from RP around 7:30 am. However, staff at that time had not observed resident to have a cough. Therefore, it was impossible to notify RP during the call.

Although the allegation, "staff did not notify residents authorized representative of change in health conditions immediately" 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.

Exit interview conducted with Administrator, Katherine Grutas

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda Pitcher	TELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020

LIC9099 (FAS) - (06/04)

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