079200580-6-9-2022-15-AS-HHUL-CK6PQ8-20221013113041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 06/09/2022
Date Signed: 06/09/2022 04:11:47 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
06/01/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20210601150555

FACILITY NAME:	HEATHERWOOD MEMORY CARE		FACILITY NUMBER:	079200580
ADMINISTRATOR:	FERNANDEZ, RYAN		FACILITY TYPE:	740
ADDRESS:	1315 MT PISGAH ROAD		TELEPHONE:	(925) 939-2833
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94596
CAPACITY:	32	CENSUS: 26	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Ritchie Gonzales, Assistant Administrator Katelyn Wilson, Nurse		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained a pressure injury while in care
Residents sustained unexplained injuries while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 6/9/2022 Licensing Program Analysts (LPA) L. Ibo arrived unannounced to deliver complaint findings for the above allegations. LPA met with Katelyn Wilson, Nurse & Ritchie Gonzales, Assistant Administrator, LPA explained the purpose of the visit.

Allegation: Resident sustained a pressure injury while in care

During the course of investigation, R1 was admitted at the facility on October 2020 from the hospital with redness on her bottom. Based on records review, facility staff immediately informed facility management team. On 3/1/2021 R1’s Hospice agency ordered medication for stage two pressure sore and also instructed staff to have R1 off load pressure to buttocks every two hours. Based on interview and records review, staff has been repositioning R1 at least every two hours and applying medication on her buttocks. Based on records review R1’s pressure sore did not progress and healed properly.
…continue to LIC9099C…

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

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 2

Control Number 15-AS-20210601150555

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: HEATHERWOOD MEMORY CARE	FACILITY NUMBER: 079200580
	VISIT DATE: 06/09/2022

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

Allegation: Residents sustained unexplained injuries while in care

Based on interview and records review, on 1/5/2021 staff documented that R1 had bruises on both legs, based on staff investigation the bruises were from R1’s both leg bumping on her wheelchair’s footrest. Staff placed wedge pillow to keep R1’s legs from hitting the wheelchair’s footrest. No further injury or bruises.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has not been met, therefore the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 2