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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200030
Report Date: 04/28/2022
Date Signed: 07/06/2022 05:01:01 PM

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
12/28/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20211228104311
FACILITY NAME:CROW CANYON RESIDENTIAL CARE IVFACILITY NUMBER:
079200030
ADMINISTRATOR:RUFFY B. YUFACILITY TYPE:
735
ADDRESS:1385 JENSEN DRIVETELEPHONE:
(925) 432-8786
CITY:PITTSBURGSTATE: CAZIP CODE:
94565
CAPACITY:6CENSUS: 5DATE:
04/28/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ruffy Yu, AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident sustained multiple pressure injuries while in care
INVESTIGATION FINDINGS:
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Amended report
On 07/06/22, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to amend and redeliver the finding of above allegation. LPA explained the purpose of the visit with administrator.

Allegation: Resident sustained multiple pressure injuries while in care
Investigation Finding: SUBSTANTIATED
Per records review and staff interviews it was found that C1 was non-ambulatory and incontinent. S1 and S2 reported that C1 required toileting and bathing assistance; and C1s incontinent garment was to be checked and/or changed 4x per day.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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 2
Control Number 15-AS-20211228104311
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: CROW CANYON RESIDENTIAL CARE IV
FACILITY NUMBER: 079200030
VISIT DATE: 04/28/2022
NARRATIVE
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Hospital records indicate that C1 was admitted on 12/26/21 for difficulty swallowing and not following commands; however, medical staff observed upon presentation that C1 had developing deep tissue injuries at the sacral and right ischial areas, with 90% chance of evolving into Stage 3-4 pressure injuries.

The Department has investigated this allegation, and per records review and interviews has found that the preponderance of evidence standard has been met, therefore, the allegation is Substantiated. Deficiency cited on the 809D form, per California Code of Regulations, Title 22, Division 6, Chapter 8.

A $500.00 immediate civil penalty is assessed due to the wound injuries.

Failure to correct the deficiency by the POC date may result in additional Civil Penalties. Exit interview conducted and a copy of this report and the Appeal Rights was provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2