079200580-6-4-2021-15-AS-KHOS-C3SNWS-20210608105001

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 06/04/2021
Date Signed: 06/04/2021 04:49:43 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
04/13/2020 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200413113205

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:	01:00 PM
MET WITH:	Ryan Fernandez, Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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-Residents room has bed begs
-Staff failed to properly prepare food
-Facility staff fails to follow a menu for residents
-Facility staff failed to meet resident needs

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 phone conference.

It was alleged that the facility failed to address a bed bug infestation. During the investigation, LPA conducted interviews and reviewed documentation related to the allegation. On 3/26/20, Orkin pest control inspected the facility and treated bed bugs found in a resident bedroom. Administrator replaced mattress as a precaution and temporarily moved resident to a new room while the resident's room was getting treated. In addition, every item of resident's clothing was bagged, washed, and cleaned. Subsequent service visits from Orkin revealed the facility was free of bed bugs. The department determined although the facility did in fact have an issue with bed bugs, the facility took the proper measure in addressing the problem.

[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-20200413113205

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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It was alleged that around April 2020, meals were not cooked for safe consumption. LPA reviewed facility cook S3’s training and qualifications. Records indicated S3 received ongoing Food Handler training with a certificate awarded on 7/15/19 (valid until 7/15/22).

It was alleged that staff failed to follow menu and to provide nutritious meals. LPA reviewed a four-week menu plan and conducted interviews. S1 stated due to Covid-19 and the scarcity of certain food items, facility had to improvise with food. S1 provided example of difficulty obtaining ground beef therefore purchased a meat grinder and ground chicken indicating it was a healthier choice for residents. S1 stated the facility never compromised quality of food and ensured residents continued to receive nutritious and healthy meals.

It was also alleged that in April 2020, staff failed to meet residents’ needs by failing to adhere to toileting protocols. Based on evidence obtained, the facility's incontinence program provides for checking and assisting residents with their toileting needs every two hours. Based on information gathered during interviews and review of facility incontinence logs for April 2020, there was not a substantial amount of evidence to support the allegation and no independent evidence or witnesses could be obtained to support that the facility failed to meet residents' incontinence care needs.

Based on the investigation, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is 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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