079200574-2-1-2023-15-AS-BFOG-CP2THT-20230214134517

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200574
Report Date: 02/01/2023
Date Signed: 02/01/2023 11:38:57 AM

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
07/13/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20220713115740

FACILITY NAME:	ABSOLUTE CARE FOR LIFE		FACILITY NUMBER:	079200574
ADMINISTRATOR:	LEVIN, EMCY MADRIAGA		FACILITY TYPE:	740
ADDRESS:	1700 MARLESTA ROAD		TELEPHONE:	(510) 478-8926
CITY:	PINOLE	STATE: CA	ZIP CODE:	94564
CAPACITY:	6	CENSUS: 5	DATE:	02/01/2023
		UNANNOUNCED	TIME BEGAN:	11:18 AM
MET WITH:	Emcy Madriaga Levin, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not prevent resident from wandering away from facility

INVESTIGATION FINDINGS:

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On 2/1/23 at 1:00PM, Licensing Program Analysts (LPAs) Carol Fowler and P. Watson arrived unannounced to deliver complaint findings for the allegations above. LPAs met with Emcy Madriaga Levin and explained the reason for the visit.

Investigation Finding: SUBSTANTIATED

During the course of the investigation the Department interviewed 2 staff and Reporting Party (RP); and obtained & reviewed the following documents: facility and staff roster, physician's report, appraisal needs and service plan, caregiver work schedule, identification and emergency information.

Continue on 9099C

Substantiated

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: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

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-20220713115740

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: ABSOLUTE CARE FOR LIFE	FACILITY NUMBER: 079200574
	VISIT DATE: 02/01/2023

NARRATIVE

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Continue from 9099

Upon investigation it was found that R1 had eloped from the facility on 6/30/2022. S1 was preparing medication for R1, S2 asked S1 for assist with R2 in the bathroom. S1 returned to prepare medication for R1, once prepared S1 proceeded to R1’s bedroom R1 was not there. S1 searched the facility, R1 was not in the facility. The facility is equipped with an egress alarm but R2 was making loud noises while S1 and S2 was assisting her in the bathroom, staff didn’t hear the alarm. S1 walked out of the facility to look for R1, at that time R1’s brother (W1) and his wife(W2) arrived at approximately 6:45pm to the facility, S1 informed the family R1 was missing. R1’s daughter also arrived at the facility and saw S1 outside of the facility and run back in. RP knocked on the door of the facility and was informed by S1 that R1 was missing from the facility. RP, W1 and W2 then proceed to drive and search for R1. W1 & W2 found R1 approximately 3 blocks from the facility. The administrator was called an hour after R1 was missing.

R1 had scrapes and scratches on R1’s head and arm. RP took R1 to Kaiser Hospital emergency room. R1 arrived back to the facility on 6/30/2022 approximately 12:20pm. On 7/9/2022 RP moved R1 from the facility.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220713115740

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: ABSOLUTE CARE FOR LIFE	FACILITY NUMBER: 079200574
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/01/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/10/2023 Section Cited CCR 87705(b)(2)	1 2 3 4 5 6 7	(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering....	1 2 3 4 5 6 7	Administrator agreed to conduct in-service training with staff and submit a copy with attendees’ signatures. Administrator will also provide a detailed plan of preventing elopement at the facility and submit a copy to CCLD by the POC due date.
	8 9 10 11 12 13 14	Based on interviews and records review, the licensee did not comply with the section above for safety measures by R1 being able to elope which posed an immediate safety risk to person 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: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 02/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2023

LIC9099 (FAS) - (06/04)

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