079200302-6-28-2023-15-AS-KHOS-CTFLTJ-20230705090224

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200302
Report Date: 04/04/2023
Date Signed: 06/28/2023 05:40:05 PM

Unsubstantiated

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
03/10/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20230310090505

FACILITY NAME:	STUART HOUSE, THE		FACILITY NUMBER:	079200302
ADMINISTRATOR:	PAMELA GREEN		FACILITY TYPE:	740
ADDRESS:	3067 BELFAST WAY		TELEPHONE:	(510) 262-0206
CITY:	RICHMOND	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 4	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	03:05 PM
MET WITH:	PAMELA GREEN, ADMINISTRATOR		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff fail to ensure footrests were on the wheelchair

Staff did not providing proper care

INVESTIGATION FINDINGS:

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On 4/04/2023 at 3:05 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct a complaint investigation for the above allegations. Upon arrival, LPA met with by Administrator, Pamela Green and explained the reason for the visit.

During the complaint investigation, LPA interviewed RP and 2 staff. LPA collected the following documents: reviewed and obtained the following documents for R1: (physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA), hospice care plan, after visit summary, hospice plan of care order and progress notes.

CONTINUE ON LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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-20230310090505

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: STUART HOUSE, THE	FACILITY NUMBER: 079200302
	VISIT DATE: 04/04/2023

NARRATIVE

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CONTINUE FROM LIC9099

ALLEGATION: Staff fail to ensure footrests were on the wheelchair

Investigation finding: UNSUBSTANTIATED

During the course of the investigation the Department interviewed 2 staff, and reporting party (RP) LPA obtained & reviewed the following documents: Facility & staff roster, physician reports, admission agreement, identification and emergency information, and Power of Attorney (POA), hospice care plan, after visit summary, hospice plan of care order and progress notes.

Interview wit's been requested and order. S1 stated that S1 uses a wheelchair that belonged to R2 to bring R1 to the visiting area and is then put into a recliner with pillows and warming blankets for visits.

ALLEGATION: Staff did not providing proper care

Investigation finding: UNSUBSTANTIATED

During the course of the investigation the Department interviewed 2 staff and reporting party (RP).

Interview with staff and record review revealed hospice nurse and in home care aid is visiting the facility 3 times a week and is taking care of R1. Hospice nurse is caring for R1's diagnoses, the in-home care aid is taking care of R1 hygiene.

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.

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

LIC9099 (FAS) - (06/04)

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