079200580-10-21-2022-15-AS-KHOS-CKLN3Z-20221027100711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 10/21/2022
Date Signed: 10/21/2022 11:46:07 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
05/24/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220524155410

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: 25	DATE:	10/21/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Katelyn Wilson, Assistant Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff force resident to wear a face covering
Staff do not perform proper hand hygiene
Medication is accessible to residents in care
Residents in care are not provided with hygiene items of general use

INVESTIGATION FINDINGS:

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On 10/21/2022 at 9:20AM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct a subsequence complaint investigation in regard to the above allegations and delivered investigation findings. LPA met with Assistant Administrator Katelyn Wilson and informed her the reason for visit. Another Assistant Administrator Ritchle Gonzales arrived at 11:20AM.

Allegation: Staff force resident to wear a face covering – Unsubstantiated
The Department has investigated this allegation and per record review and interviews found that staff force resident to wear a face covering was not witnessed by other staff and witnesses. It was not observed by LPA during visits.

Continue on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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-20220524155410

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: HEATHERWOOD MEMORY CARE	FACILITY NUMBER: 079200580
	VISIT DATE: 10/21/2022

NARRATIVE

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Allegation: Staff do not perform proper hand hygiene – Unsubstantiated

The Department has investigated this allegation and per record review and interviews found that the cook and kitchen helper were observed wearing face mask and gloves while working in kitchen, their changing gloves was also observed during visits. Hand washing station with soap, paper towels, and handwashing signs was observed in the kitchen.

Allegation: Medication is accessible to residents in care – Unsubstantiated

The Department has investigated this allegation and per record review and interviews found that medication was observed to be locked at all time during visits. Other staff and witnesses have not witnessed medication was accessible to residents. No incident report of resident took other resident medication was found on file in subject time period.

Allegation: Residents in care are not provided with hygiene items of general use – Unsubstantiated

The Department has investigated this allegation and per record review and interviews found that adequate hand soap, toilet paper, and paper towels were observed in common bathrooms and resident’s bathrooms during visits. Witnesses stated that soap and paper towels were always available in the bathrooms.

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

Exit interview conducted with Assistant Administrator and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC9099 (FAS) - (06/04)

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