<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200578
Report Date: 11/16/2022
Date Signed: 11/16/2022 04:17:53 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
06/29/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210629164337
FACILITY NAME:CORDIAL CARE HOMEFACILITY NUMBER:
079200578
ADMINISTRATOR:OKEIGWE, OGEDIFACILITY TYPE:
740
ADDRESS:2957 HANNAN DRIVETELEPHONE:
(925) 947-5812
CITY:PLEASANT HILLSTATE: CAZIP CODE:
94523
CAPACITY:6CENSUS: 5DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Winifred 'Willie' Wepee/Facility ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident (R1) developed pressure injury while in care.

Facility failed to meet resident's (R1) care needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the findings for the above allegations. LPA met with Winifred 'Willie' Wepee, facility manager. LPA called and spoke with Ogedi Okeigwe, administrator. LPA informed both the facility manager and administrator the reason for visit.

It was alleged that R1 was admitted to the facility on 3/08/2021, but did not have hospital bed. R1 was left in the wheelchair overnight. It was further alleged that R1 was sent out to the hospital where he was found to have developed pressure injury and with dried feces on buttocks.


......continued on 9099C (page 2)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
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 4
Control Number 15-AS-20210629164337
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: CORDIAL CARE HOME
FACILITY NUMBER: 079200578
VISIT DATE: 11/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

During the course of investigation, the Department obtained copies of R1’s documents including but not limited to the following: medical records; LIC601 Identification and Emergency Information; Admission Agreement; LIC602A Physician's Report; Pre-placement Appraisal; hospital documents. Copies of LIC9020 Register of Facility Clients/Residents and LIC500 Personnel Report were obtained, and interviews conducted.

Medical records showed R1 was admitted to the hospital on 3/09/2021 with generalized buttocks pain. R1 was observed with skin breakdown but no pressure injury, wounds or incision. Medical records also revealed R1 had large amount of soft stool that appears to have been on R1’s skin for some time as it was difficult to remove and dried in some areas. R1 indicated that he tell the facility staff that he had bowel movement but sometimes it takes a while for them to clean him up. Staff (S1) stated when R1 moved-in, R1’s hospital bed and lift was not delivered that night and R1 slept in a wheelchair all night, because the facility didn’t have a lift. R1 was discharged back to the facility on 3/10/2021 with after care instructions on how to care for non-specific dermatitis.

On 03/30/2021, R1 was visited by Home Health at the facility and was observed with altered mental state. R1 was sent out and admitted to the hospital with final diagnosis of severe sepsis with acute organ dysfunction and unstageable pressure injury of sacrum/buttocks.

Staff interviews were conducted, and staff (S1 & S2) had a hard time recalling if R1 had pressure injury. S1 indicated that on the day of admission to the facility, R1’s hospital bed was delivered but not accepted by the facility due to bed was not electric.

.......continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20210629164337
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: CORDIAL CARE HOME
FACILITY NUMBER: 079200578
VISIT DATE: 11/16/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 3

Director for Home Health and Hospice (HHD) stated R1 receives home health care for catheter care and seen by home health nurse twice a week. HHD stated that on 03/09/2021, home health called the facility to schedule a visit but was notified that R1 was at the hospital. Home Health nurse (HH) was interviewed who stated that R1 had stage 1 pressure injury and unstageable deep tissue pressure injury while at the facility’s care. HH indicated that R1 could have developed the first pressure injury for spending the night at R1’s wheelchair. HH went over the care of pressure wounds with the staff.

Based on records review and interviews, allegations of “Resident (R1) developed pressure injury while in care”, and “Facility failed to meet resident's (R1) care needs.” are substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies are cited from Title 22 California Code of Regulations and listed on 9099D. A $500.00 civil penalty is assessed. Failure to submit proof of corrections by plan of correction due dates may result in additional civil penalties.

Deficiencies, plan and proof of corrections and civil penalty were discussed with the administrator over the phone in the presence of the facility manager.

Exit interview conducted. Appeal Rights, LIC421IM Civil Penalty, LIC9098 Proof of Correction form and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20210629164337
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: CORDIAL CARE HOME
FACILITY NUMBER: 079200578
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/17/2022
Section Cited
HSC
1569.269(a)(6)
1
2
3
4
5
6
7
§1569.269 Enumerated rights; severability: (a) Residents of residential care facilities for the elderly shall have all of the following rights:(6) To care, supervision, and services that meet their individual needs and are delivered
-This requirement is not met as evidenced by:
..
1
2
3
4
5
6
7
R1 is no longer at the facility.
Administratror to in-service the staff. Copy of in-service training with attendees signatures to be submiited by 11/17/2022.

A$500.00 civil penalty is assessed on this day.
8
9
10
11
12
13
14
-Based on records review and interviews, the licensee did not comply with the section above for R1 who developed unstageable pressure injury. R1 also sustained severe sepsis and acure organ dysfunction while in care which posed immediate health risk to person in care. Civil penalty is assessed.
8
9
10
11
12
13
14
Type B
11/30/2022
Section Cited
CCR
87464(f)(1)
1
2
3
4
5
6
7
87464 Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
-This requirement is not met as evidenced by:
..
1
2
3
4
5
6
7
R1 is no longer at the facility.
Administratror to in-service the staff and ensure residents' care needs are met. Copy of in-service training with attendees signatures to be submiited by 11/30/2022.
8
9
10
11
12
13
14
--Based on records review and interviews, the licensee did not comply with the section above for not meeting R1's needs, R1 was found to have dried feces when sent out to the hospital.
8
9
10
11
12
13
14
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: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4