079200580-6-4-2021-15-AS-KHOS-C3THVX-20210609063239

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 06/04/2021
Date Signed: 06/04/2021 04:46:49 PM

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
03/24/2020 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200324104838

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: 19	DATE:	06/04/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ryan Fernandez, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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-Facility had a questionable death
-Staff is denying residents from having visitors
-Staff is not seeking timely medical attention for residents
-Staff is providing care and supervision when ill

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this inspection with Administrator Ryan Hernandez to deliver findings on the above allegations. Due to the present shelter in place order by the Governor, this inspection was conducted via phonce conference.

It was alleged that a male resident who appeared stable suddenly died in March 2020. Based on facility records, the only male resident to have passed away in the month of March 2020 was R1. R1’s records indicated R1 was under the care of Suncrest Hospice since 2/13/20 and passed away on 3/22/20 without any indication from the Hospice agency/nurse that R1’s death was suspicious or unusual.

[See LIC9099-C for continued report]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

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-20200324104838

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: 06/04/2021

NARRATIVE

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In regards to the allegation that staff were denying residents from having visitors, the facility was following strict health and safety guidelines imposed by the Contra Costa County Public Health and Community Care Licensing Division (CCLD) during the pandemic. A letter dated March 12, 2020, informed residents that in an effort to reduce Covid-19 exposure, the facility would be suspending all non-emergency and non-clinical visitation.

It was also alleged that the facility was failing to seek timely medical attention for residents feeling unwell. Based on interviews and recommended Public Health guidelines around March 2020, residents were discouraged to go to the hospital for non-life-threatening issues due to high risk of exposure to Covid-19.

In regards to the allegation that staff were providing care and supervision to residents while ill, based on information gathered, there was not a substantial amount of evidence to support the allegation and no independent evidence or witnesses could be obtained to support that staff were required to work while being ill. Rapid Assistance and Support Team (RAST) tele-visits conducted by CCLD in March 2020, revealed the facility was aware and following health and safety protocols and guidelines in regards to monitoring and screening all staff prior to entering the facility for their work shift.

Based on the investigation, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen Singh	TELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021

LIC9099 (FAS) - (06/04)

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