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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 06/17/2021
Date Signed: 06/17/2021 05:20:33 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
12/08/2020 and conducted by Evaluator Praveen Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20201208121956
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:32CENSUS: 19DATE:
06/17/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Ryan Fernandez, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Administrator to deliver findings on the above allegation. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference.

This complaint allegation was accepted by the Department's Investigations Branch (IB) as a full investigation. The Department reviewed records and conducted interviews. Based on the investigation, it was determined there was sufficient evidence to substantiate that facility staff did not seek timely medical attention for R1.


[See LIC9099-C for continued report.]
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (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)
Page: 1 of 5
Control Number 15-AS-20201208121956
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: 06/17/2021
NARRATIVE
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R1 has a diagnosis of esophageal stricture. R1 had a couple of incidents in the past related to this before moving to the facility but learned how to manage it. On 10/31/20, R1’s wife and personal caregiver observed R1 appeared to have blockage in his esophagus. Later when staff were notified of the situation, at the request and urging of R1’s wife, who is a nurse by trade and familiar with R1's condition, staff did not immediately seek medical attention for R1, going against facility protocol. Staff waited several hours before sending R1 to the hospital. R1 developed pneumonia and was moved to the Transitional Care Unit (TCU) where an endoscopy was done, and a marble sized piece of food was removed.

Based on the information gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies are cited per California Code of Regulations, Title 22, Division 6 and Chapter 8 on the attached LIC9099-Ds. Exit interview conducted and copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/08/2020 and conducted by Evaluator Praveen Singh
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20201208121956

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:32CENSUS: DATE:
06/17/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Ryan Fernandez, AdministratorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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-Staff did not adequately supervise resident during an incident
-Staff did not follow resident's care plan
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Praveen Singh conducted this unannounced tele-visit with Administrator to deliver findings on the above allegations. Due to the present shelter in place order by the Governor, this inspection was conducted via video-conference.

This complaint allegation was accepted by the Department's Investigations Branch (IB) as a full investigation. The Department reviewed records and conducted interviews.

During the course of this investigation, there was insufficient evidence to substantiate that facility staff did not provide adequate supervision resulting in R1 getting food stuff in his esophagus. At the time of the incident in question, R1 was having dinner with his private caregiver present and his wife on FaceTime. The private caregiver and R1’s wife did not immediately notify staff of the situation.

[See LIC9099-C for continued report]
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (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)
Page: 4 of 5
Control Number 15-AS-20201208121956
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: 06/17/2021
NARRATIVE
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It was also alleged that facility failed to follow R1’s care plan in regard’s to R1’s medical condition. Based on the evidence obtained, R1 had no dietary mechanical needs and only required a low salt diet. R1 was able to eat independently. R1 did not require supervision but at the time of the incident, his private caregiver was present.

This agency has investigated the complaint allegations. We have found that the complaint was unfounded, meaning that the allegations were false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (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
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20201208121956
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: 06/17/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Administrator states:
1. in service training on Sec 87465(a)(1) will be conducted
2. Administrator will read Sec87465(a)(1) and submit self-certification of understanding

Proof of correction will be sent to LPA Singh via email by POC date.
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This requirement is not met as evidenced by: Staff waited to call 911 several hours after becoming aware of R1’s acute medical difficulties.
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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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5