075601536-1-23-2026-15-AS-HHUL-DQR2DM-20260127161831

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 075601536
Report Date: 01/23/2026
Date Signed: 01/23/2026 09:00:45 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
10/13/2025 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20251013102712

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: 14	DATE:	01/23/2026
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	MedTech Gemma James		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff handled resident in a rough manner causing fracture.

INVESTIGATION FINDINGS:

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On 01/23/2026, at 8:30 AM, Licensing Program Analyst (LPA) James Sampair arrived unannounced to deliver findings on the allegation above. The LPA informed MedTech Gemma James of the reason for the visit.

The Department's investigation included, but was not limited to, interviews with staff and a review of the records pertaining to Resident R1, which included facility records and medical records. The Department also inspected the facility, interviewed staff, and reviewed facility video recordings containing Resident R1.

The complaint alleges that staff handled R1 in a rough manner causing a fracture.
R1 is a resident who relies on staff for all activities of daily living. On 10/10/2025, R1 was taken to the emergency department by her daughter due to right arm pain and swelling. The X-ray showed a “spirally oriented fracture of the distal shaft of the ulna” with degenerative changes. The emergency department physician noted that spiral fractures typically occur with pulling or twisting of the arm.

Continued on LIC 9099-C . . .

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

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-20251013102712

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: CARNELIAN I	FACILITY NUMBER: 075601536
	VISIT DATE: 01/23/2026

NARRATIVE

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. . . Continued from LIC 9099

On 10/15/2025, a physician specializing in orthopedics examined R1 and reviewed X-rays that revealed a minimally displaced long oblique/spiral fracture of the distal ulnar shaft. The specialist explained that such fractures are usually caused by direct impact, though twisting could not be ruled out. He stated that the injury was not a major cause of concern for possible abuse and appeared instead to be a "common" type of injury due to R1's osteoporosis. This was because R1 had osteoporosis, and the injury could have occurred if she hit her arm on something, or if her arm was caught in the hospital bed and R1 twisted her arm in an attempt to “get free” from the hospital bed.

The daughter reported she has never observed staff handling R1 in a rough manner. Staff interviewed stated they always assist R1 by supporting her under the armpits during transfers from bed to wheelchair and have never pulled her arms. The resident’s room is equipped with a motion sensor and a bed alarm that alerts caregivers when R1 attempts to get out of bed, and caregivers have not witnessed any falls. In October, R1 began sleeping in a hospital bed with safety rails. On one occasion, staff observed that her arm appeared to be stuck in the bed rails, as if she had “tangled herself” in the safety railings of her bed. No further issues with the bed railings have been observed since then.

According to interviews, review of facility records and video tapes, and a review of R1’s medical records, there was no indication that R1 was handled in a rough manner by staff causing a fracture. The data analyzed does not support the allegation.

Although the allegation may have happened, or is valid, there is not a preponderance of evidence to prove it; therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:	DATE: 01/23/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/23/2026

LIC9099 (FAS) - (06/04)

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