079200580-7-8-2022-15-AS-KHOS-CGQNHK-20220727102853

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200580
Report Date: 07/08/2022
Date Signed: 07/08/2022 01:41:13 PM

Unsubstantiated

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
06/28/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220628135729

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: 23	DATE:	07/08/2022
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Ritchie Gonzales, Assistant Administrator		TIME COMPLETED:	01:55 PM

ALLEGATION(S):

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Staff do not provide proper medication assistance to residents in care
Facility does not have adequate food supply
Facility does not have a signal system for residents in care

INVESTIGATION FINDINGS:

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On 7/8/2022 at 10:25 AM, Licensing Program Analysts (LPAs) L. Francisco and K. Nguyen arrived unannounced to conduct a complaint investigation for the above allegations. Upon arrival, LPAs met with by Activity Director, Helen McCauley and explained the reason for the visit. Assistant Administrator, Ritchie Gonzales later arrived at 10:45 AM.

During the complaint investigation, LPAs toured facility with Assistant Administrator. LPAs reviewed records, interviewed staff and collected documents. It was alleged staff did not provide proper medication assistance to residents in care. Based on information obtained by complainant, residents are not receiving their bedtime medications because no med-tech staff are scheduled on shift during those times.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

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-20220628135729

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: 07/08/2022

NARRATIVE

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LPAs reviewed staff schedule and observed med-techs are scheduled until 7:30 PM. LPAs reviewed a sample of six (6) resident's medication and observed 1 of 6 residents has two bedtime medications to be administered at 8 PM. However, during an interview with S1 and S2, LPAs discovered that staff administers resident's (R1) medications a half hour to an hour before 8 PM and med-techs would often stay until 8 PM. LPAs reviewed R1's Medication Administration Record (MAR) and observed R1 is receiving both 8 PM medications.

It was alleged facility does not have adequate food supply. However, LPAs inspected food supply at 10:56 AM and observed facility maintains a two day perishable and one week non-perishable food supply. LPAs reviewed a sample of receipts and observed food supplies were purchased on 6/28/2022, 7/4/2022 and 7/7/2022.

It was alleged facility does not have a signal system in residents room. No forthcoming information from complainant. Therefore, LPAs were unable to determine which resident does not have a signal system or the type of signal system. However, LPAs toured 4 random rooms and observed an auditory signal for two residents with doors exiting to the front courtyard of facility, a fall motion sensor for fall risk resident and a bed alarm.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with Assistant Administrator and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022

LIC9099 (FAS) - (06/04)

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