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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200390
Report Date: 04/25/2024
Date Signed: 04/25/2024 12:30:26 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
04/19/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240419113325
FACILITY NAME:ANGEL'S CREST HOME IIFACILITY NUMBER:
079200390
ADMINISTRATOR:MARIVIE FABIEFACILITY TYPE:
740
ADDRESS:1864 CAMINO RAMONTELEPHONE:
(707) 315-9664
CITY:DANVILLESTATE: CAZIP CODE:
94526
CAPACITY:6CENSUS: 4DATE:
04/25/2024
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Marvie FabieTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Staff inappropriately restrains resident in care.
INVESTIGATION FINDINGS:
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On 4/25/2024 at 10:50AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct complaint investigation and to deliver complaint findings for the above allegations. At 11:30AM LPA met with Administrator, Marvie Fabie and explained the purpose of the visit.

During the investigation LPA interviewed the Administrator and S1, reviewed resident records, and reffered to photos submitted by the RP. While interviewing S1 they disclosed that sometime last week the facility had a visit. During the visit S1 was questioned as to why R1 had a lapbelt keeping them on their wheelchair that latched in the back. S1 stated it was to protect them and that R1's responsible party requested the use of a lap belt. The visitor asked if R1 had a physicians order for the lap belt to which S1 said they did not know.

Report continues on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
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 3
Control Number 15-AS-20240419113325
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: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390
VISIT DATE: 04/25/2024
NARRATIVE
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While interviewing the Administrator they stated that R1 has dementia and kept falling. When R1 was put on hospice their responsible party inquired about options to help R1 from falling out of chairs. Administrator states that they informed the responsible party that restraints are not allowed but that the responsible party said it should be considered protection and comfort since R1 is on hospice. The Administrator acknowledges that the restraint was used improperly and that they will request an exception from CCLD to use a proper restraint. Administrator states that no restraints are/will be in use until an exeption is made.

During the investigation LPA reviewed the records, physicians report and care plan for R1. LPA did not observe any documentation allowing restraints. R1 is on hospice.

LPA also referenced photos submitted by the RP that shows R1 restrained in their wheelchair with the latch being wrapped around the bar behind the wheelchair where R1 can not reach it and easily get out.


Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20240419113325
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: ANGEL'S CREST HOME II
FACILITY NUMBER: 079200390
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/26/2024
Section Cited
CCR
87608(a)(2)(3)
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(a)Based on the individual's preadmission...Postural supports may be used under the following conditions.(2)Postural supports shall be fastened or tied in a manner that permits quick release by the resident.(3)A written order from a physician... The licensing agency shall ... verify the order.

This requirement was not met as evidence by:
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LPA observed that belt has been removed and Administrator agreed to request an expetion and physicians report before utilizing the lap belt.
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Based on interviews, record review, and validated photos R1 was improperly restrained with a lap belt that did not offer quick release and did not have a physicians order.
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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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3