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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 02/14/2024
Date Signed: 02/14/2024 12:58:42 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
08/31/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220831135353
FACILITY NAME:HEATHERWOOD MEMORY CAREFACILITY NUMBER:
079200580
ADMINISTRATOR:FERNANDEZ, RYANFACILITY TYPE:
740
ADDRESS:1315 MT PISGAH ROADTELEPHONE:
(925) 939-2833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:0CENSUS: 27DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ritchie Gonzalez, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Resident sustained an unexplained fracture while in care
INVESTIGATION FINDINGS:
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On 02/14/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, Needs & services plans, centrally stored medication logs, medication administration records, hospital discharge summary reports and incident reports.

Continued on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
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 7
Control Number 15-AS-20220831135353
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: 02/14/2024
NARRATIVE
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Allegation: Resident sustained an unexplained fracture while in care
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s records showed she was first admitted at the facility on 02/02/22. R1 was assessed as ambulatory, able to transfer from bed to chair unassisted and a high risk for falls.

On 07/08/22, staff (S1) observed R1’ s left leg was swollen. Facility notes dated 7/9/2022 show communications to S2 that S3 tried to get R1 up from bed and R1 was yelling. Same notes state R1 has been complaining of hip pain since 7/6/2022. R1 spent 7/9/2022 - 7/11/2022 in bed. On 07/10/22, staff notified authorized representative (POA) of R1’s leg pain possibly associated with R1’s heel wound. Interview of POA revealed that facility staff did not inform her of the severity of R1 seemed to be experiencing of swollen and inverted leg or of any visible injuries.

Facility messages between S1, S2, S3, and S4 (ADM) state POA decided not to send R1 to the hospital until she was seen by the home health wound care nurse. On 07/12/22, home health nurse conducted an assessment on R1 with W2 present and observed her left leg to be swollen and inverted with bruising to the upper inner thigh. Interview with W2 revealed that facility staff did not communicate to W2 about bruising to the upper inner thigh. Home health notes indicate there could be a possible injury to the hip and blood clot with recommendation to follow up with physician. Home health nurse observed R1 to be in pain but was unable to verbally express anything. There were no additional notes from the facility or medical records to indicate that the facility followed up with R1’s physician or seek advice from the advice nurse on beginning on 7/6/2022 through 7/14/2022.

Continued on 9099-C1
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 15-AS-20220831135353
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: 02/14/2024
NARRATIVE
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Interview of S4 stated that he received a phone call from home health on 7/15/2022 requesting he contact Kaiser advice nurse about the leg pain R1 was experiencing. On 07/15/22, the facility contacted Kaiser Permanente advice nurse and advised facility to send R1 to the hospital for evaluation. R1 was admitted to Kaiser Permanente Walnut Creek on 7/15/2022. On physical examination attending physician noted, “Patient winces in pain with palpation or movement of the left hip and grabs her groin.” Staff stated there were no significant incidents that would have caused a fracture and denied any falls but could not explain why R1’s leg was inverted. An x-ray was conducted and R1 was diagnosed with an intertrochanteric femur fracture on her left side. On physical examination attending physician noted, “Patient winces in pain with palpation or movement of the left hip and grabs her groin.” Staff stated there were no significant incidents that would have caused a fracture and denied any falls but could not explain why R1’s leg was inverted.

Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that resident sustained an unexplained fracture while in care was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POC) by plan of correction due dates and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted, appeal rights and copy of report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20220831135353
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/29/2024
Section Cited
CCR
87468
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When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person.
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By POC due date, administrator agreed to complete and submit in-service staff training on proper observation of resident to include assessment protocols or procedures in compliance with Title 22 Section 87466.
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This requirement was not met as evidenced by staff failing to address resident’s change in condition with R1 medical provider and not informing R1’s responsible person of the bruising, swollen and inverted leg which posed a potential health & safety risk to residents in care
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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
08/31/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220831135353

FACILITY NAME:HEATHERWOOD MEMORY CAREFACILITY NUMBER:
079200580
ADMINISTRATOR:FERNANDEZ, RYANFACILITY TYPE:
740
ADDRESS:1315 MT PISGAH ROADTELEPHONE:
(925) 939-2833
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94596
CAPACITY:0CENSUS: 27DATE:
02/14/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Ritchie Gonzalez, AdministratorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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2
3
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9
Resident sustained a pressure injury while in care
Staff did not seek medical attention to resident in a timely manner
INVESTIGATION FINDINGS:
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On 02/14/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver the finding of above allegation. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, Needs & services plans, centrally stored medication logs, medication administration records, hospital discharge summary reports and incident reports.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20220831135353
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: 02/14/2024
NARRATIVE
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Allegation: Resident sustained a pressure injury while in care
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s records showed that on 07/10/22 S3 notified R1’s authorized representative (POA) of a wound developing on her left heel and scheduled a home health nurse to evaluate and treat R1. Facility staff believed the wound was forming from shoes and stopped putting the shoes on R1.

On 07/12/22, the home health nurse assessed R1’s left heel wound and noted that it was not infected. Home health records indicate the wound to the left heel was consistent with stage 2 pressure ulcer. Home health did not return back to the facility to provide treatment as R1 was sent to Kaiser Permanente Walnut Creek on 7/15/2022 and did not return back to the community.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident sustained a pressure injury while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that resident sustained a pressure injury while in care is unsubstantiated.

Continued on next page 9099-C1
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20220831135353
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: 02/14/2024
NARRATIVE
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Allegation: Staff did not seek medical attention to resident in a timely manner
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of facility communications showed that on 0710/22 S1 notified R1’s authorized representative (POA) of left leg pain possibly associated with a wound on her heel. POA decided not to send R1 to the hospital until she was seen by the home health nurse.

On 07/12/22, the home health nurse observed R1’s left leg swollen and inverted. Home health nurse recommended to follow up with physician. Interview of POA revealed that facility staff did not inform her of the severity of R1 seemed to be experiencing of swollen and inverted leg or of any visible injuries. Facility messages between S1, S2, S3, and S4 (ADM) state that the facility was waiting for R1’s POA and W2 to decide what to do. Facility care notes and communications did not show there was any communication to R1 physician or advice line until 7/15/2022.

On 07/15/22, R1 was sent to the hospital and diagnosed with a intertrochanteric femur fracture on her left side. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff did not seek medical attention to resident in a timely manner and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not seek medical attention to resident in a timely manner is unsubstantiated.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7