079200580-1-26-2023-15-AS-HHUL-CP5N85-20230217091347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 01/26/2023
Date Signed: 01/26/2023 02:57:47 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
07/06/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220706160439

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: 23	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Ritchie Gonzales, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Questionable death
Staff did not assist resident with their feeding needs
Staff does not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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On 1/26/2023 starting at 10:10 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to deliver findings for the above allegations. Upon arrival, LPAs met with Assistant Administrator, Katelyn Wilson. Administrator, Ritchie Gonazles later arrived at 10:30 AM.

During the course of the investigation, LPAs obtained information, reviewed records, collected documents, interviewed staff and residents. It was alleged there was a questionable death and staff did not assist resident with their feeding needs. Based on record review of death report, resident (R1) was under hospice care and it was noted that resident's appetite has declined. LPAs reviewed a copy of R1's weight record, and LPAs did not observe an unusual weight loss from November 2021 to May 2022. According to S1, facility was unable to weigh resident due to being bed bound in the month of June and July of 2022.

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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20220706160439

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: 01/26/2023

NARRATIVE

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6 of 6 staff stated residents are served 3 meals a day with two snacks in between. If residents requests additional servings, then residents are provided additional food. Based on interview with 2 residents, 2 of 2 stated that they are given enough food and have no complaints.

It was alleged staff does not treat resident with dignity and respect. Based on information obtained by complainant, staff puts socks on R2's hand as a prevention of scratching R2's body. However, LPAs reviewed a doctor's order for mittens from hospice. S1 stated that hospice verbally told facility that staff can put a clean socks on R2's hand if mittens are not available.

Although the allegations may have happened or are valid, there are 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 to Administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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