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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 075601577
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:23:12 PM

Substantiated


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
08/31/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230831144512
FACILITY NAME:RN3 LOVING CARE HOME IVFACILITY NUMBER:
075601577
ADMINISTRATOR:WU, MEINAFACILITY TYPE:
740
ADDRESS:8320 BUCKINGHAM DRIVETELEPHONE:
(510) 439-7063
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:8CENSUS: 7DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Meina WuTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained a fracture due to insufficient care by staff
INVESTIGATION FINDINGS:
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On 09/09/2024 at 12:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Meina Wu of the reason for the visit.

The Department's investigation included, but was not limited to, interviews with staff, residents, and the Reporting Party (RP). The Department obtained and reviewed records pertaining to resident R1, which included facility records, medical records, home health records, hospice records, and death certificate.

Continued on LIC 9099-C . . .
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
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
Control Number 15-AS-20230831144512
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: RN3 LOVING CARE HOME IV
FACILITY NUMBER: 075601577
VISIT DATE: 09/09/2024
NARRATIVE
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Continued from LIC 9099-A

The complaint alleges that resident R1 sustained a fracture while in care.

R1 was a 90-year-old female with reduced bone strength due to osteoporosis putting her at a significantly higher risk of sustaining a fracture after a fall. Interviews of the administrator and staff revealed that R1 fell sometime in early February of 2022 (specific date unknown due to lack of documentation nor report of the incident to the Department). After R1’s fall, staff did not secure immediate medical care for R1. On 2/21/2022, after R1 complained of being in “extreme pain”, the family transported R1 to the Kaiser Permanente Hospital. Kaiser Permanente medical records from 02/21/2022 show that R1 had sustained a new compression fracture of the T12 vertebrae.

When interviewed, neither the administrator nor most staff members considered R1 to have a risk of falling during the 4 years she lived at the facility. The 03/17/2020 Physician’s Report did state that R1 had a risk of falling, as did the 02/21/2022 Physician’s Report after her fall. Medical records, home health records, and Kaiser Permanente Hospice records all state that R1 was at risk of falling.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099-D.

A $500 immediate civil penalty is assessed today; Licensee was informed that additional civil penalties are still being determined based on Health & Safety Code 1569.49(f).

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

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/31/2023 and conducted by Evaluator James Sampair
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230831144512

FACILITY NAME:RN3 LOVING CARE HOME IVFACILITY NUMBER:
075601577
ADMINISTRATOR:WU, MEINAFACILITY TYPE:
740
ADDRESS:8320 BUCKINGHAM DRIVETELEPHONE:
(510) 439-7063
CITY:EL CERRITOSTATE: CAZIP CODE:
94530
CAPACITY:8CENSUS: 7DATE:
09/09/2024
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Meina WuTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained a stage 4 pressure injury due to lack of care by staff
INVESTIGATION FINDINGS:
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On 09/09/2024 at 12:00 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to deliver findings on the allegations above. The LPA informed Meina Wu of the reason for the visit.

The Department's investigation included, but was not limited to, interviews with staff, residents, and the Reporting Party (RP). The Department obtained and reviewed records pertaining to Resident R1, which included facility records, medical records, home health records, hospice records, and death certificate.

Continued on LIC 9099-C . . .
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
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-20230831144512
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: RN3 LOVING CARE HOME IV
FACILITY NUMBER: 075601577
VISIT DATE: 09/09/2024
NARRATIVE
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Continued from LIC 9099-A

The complaint alleges that Resident R1 sustained a stage 4 pressure injury due to lack of care by staff.

R1 developed a pressure injury on her left heel and began receiving wound care from home health. The wound eventually went away but began again within a few weeks. R1 began home health again but had two pressure injuries, one on her heel and the other on the coccyx. The wound on the coccyx got worse and R1 was placed on Hospice. The wound on R1’s coccyx continued to get worse, eventually going all the way down to the bone.

R1 was receiving home health care when the stage three pressure injury on her coccyx occurred. The pressure injury continued to get worse leading to R1 being placed back on hospice care. Oakland Kaiser Hospice Site Director N1 stated that she had no concerns with the care R1 was receiving while she was at the facility. N1 also stated that the facility staff were following instructions by rotating R1 as much as they could and were doing everything, they could for R1. N1 explained that it is normal for these wounds to happen and get worse quickly when someone whose health was declining as quickly as R1’s was.

Facility staff advised investigator that they saw the “red mark” on R1’s coccyx and that they notified the home health nurse of the mark. Facility staff was changing R1’s dressing on her wound every time they needed to and believed they were doing everything they could.

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

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

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230831144512
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: RN3 LOVING CARE HOME IV
FACILITY NUMBER: 075601577
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/10/2024
Section Cited
HSC
1569.269(a)(10)
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1569.269 Enumerated rights . . . (a) Residents of residential care facilities for the elderly shall have all of the following rights: (10) To be free from neglect . . .

This requirement is not met as evidenced by:
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A formal conference with CCLD will be scheduled at a later time. A $500.00 immediate civil penalty is assessed on this day.
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1 of the 4 facility staff identified R1’s risk of falling. Physician’s Reports before and after her fall in early February 2022 stated that R1 was at risk of falling. Due to her age and condition, facility staff were negligent by not immediately getting emergency medical care for R1 after her fall.
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Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1569.49(f)
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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) 529-9416
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5