079200390-10-28-2021-15-AS-KHOS-CGQNB4-20220727101832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200390
Report Date: 10/28/2021
Date Signed: 10/28/2021 03:09:06 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
02/04/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210204133758

FACILITY NAME:	ANGEL'S CREST HOME II		FACILITY NUMBER:	079200390
ADMINISTRATOR:	MARIVIE FABIE		FACILITY TYPE:	740
ADDRESS:	1864 CAMINO RAMON		TELEPHONE:	(707) 315-9664
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS:	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Marivie Fabie, Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Facility Administrator is resident's Power of Attorney

INVESTIGATION FINDINGS:

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On 10/28/21 at 2:05 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Carlota Martinez. Administrator, Marivie Fabie later arrived at 2:45pm.

During the course of the investigation, LPA obtained information, collected documents and interviewed 3 staff and witness. Administrator stated she was advised by lawyer to be added as resident’s (R1) Power of Attorney (POA) for medical accomodation. Based on documents obtained, LPA observed Administrator listed as POA.

Based on LPAs observation and interview and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided. An audit report will be requested.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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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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
02/04/2021 and conducted by Evaluator Lizette Francisco

COMPLAINT CONTROL NUMBER: 15-AS-20210204133758

FACILITY NAME:	ANGEL'S CREST HOME II		FACILITY NUMBER:	079200390
ADMINISTRATOR:	MARIVIE FABIE		FACILITY TYPE:	740
ADDRESS:	1864 CAMINO RAMON		TELEPHONE:	(707) 315-9664
CITY:	DANVILLE	STATE: CA	ZIP CODE:	94526
CAPACITY:	6	CENSUS:	DATE:	10/28/2021
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Marivie Fabie, Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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Facility failed to arrange appropriate transportation for resident
Facility failed to follow doctor's order for resident's booties

INVESTIGATION FINDINGS:

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On 10/28/21 at 2:05 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegation. Upon arrival, LPA met with Care Staff, Carlota Martinez. Administrator, Marivie Fabie later arrived at 2:45pm.

During the course of the investigation, LPA obtained information, collected documents and interviewed 3 staff and witness. Interview with S1 revealed S1 made arrangement with Omdad Services for R1 to be transported to the hospital. According to the documents obtained, S1 was advised by podiatrist office to admit resident to the hospital, but LPA was unable to determine whether it required R1 to be transported by ambulance.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

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-20210204133758

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: ANGEL'S CREST HOME II	FACILITY NUMBER: 079200390
	VISIT DATE: 10/28/2021

NARRATIVE

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Based on information obtained, facility failed to follow doctor’s order for resident’s booties. According to W1, instructions provided to staff were to off load pressure and contact nurse immediately if bandage dressing gets wet during R1’s shower. LPA did not observe a written instruction for booties, however, 3 of 3 staff stated resident wore booties during the day and bedtime per doctor's order. LPA observed a photo of R1's Physicial Therapist demonstrating to staff on how to elevate R1's leg on wheelchair with booties.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20210204133758

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: ANGEL'S CREST HOME II	FACILITY NUMBER: 079200390
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/28/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/03/2021 Section Cited CCR 87468.2(26)(C)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (26) To manage their financial affairs. A licensee shall not require residents to deposit their personal funds with the licensee...(C) Serve as an agent for a resident under any general or special power of attorney.	1 2 3 4 5 6 7	Administrator agrees to review regulation and submit a self-certification of having read and understood regulation and proof of documentation that Licensee has been removed as POA to CCL by POC date.
	8 9 10 11 12 13 14	Based on record review, Licensee did not comply with the regulation cited above. LPA observed Licensee is indicated as R1's power of attorney which poses a potential personal rights in persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2021

LIC9099 (FAS) - (06/04)

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