079200580-6-17-2021-15-AS-KHOS-C48M7Z-20210622092223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 06/17/2021
Date Signed: 06/17/2021 05:25:38 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
04/22/2020 and conducted by Evaluator Praveen Singh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200422162311

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:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Ryan Fernandez, Administrator		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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-Staff did not administer medication to resident in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Praveen Singh conducted this inspection with Administrator to deliver finding on the above allegation. Due to the present shelter in place order by the Governor, this inspection was conducted via phone conference.

It was alleged that R1's PRN suppository medication for constipation was expired and not given to R1 until 72 hours after R1's last bowel movement which was on 4/16/20. LPA conducted interviews and obtained R1's Centrally Stored Medication log, Medication Administration Records (MARs), and Physician's Orders. Based on the investigation, R1's PRN suppository medication was discontinued on 1/16/20 when R1 transitioned from Hospice Care to Palliative Care. R1 received a new physician's order for a PRN suppository medication on 4/19/20. Facility MARs indicate LVN administered PRN suppository medication dose to R1 on 4/19/20.

This agency has investigated the complaint allegation. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Unfounded

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: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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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