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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200609
Report Date: 04/22/2022
Date Signed: 04/22/2022 01:22:18 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
12/08/2021 and conducted by Evaluator Leslie Ibo
COMPLAINT CONTROL NUMBER: 15-AS-20211208153427
FACILITY NAME:WOODBRIDGE CLAYTONFACILITY NUMBER:
079200609
ADMINISTRATOR:MUTYA, JOHANNAFACILITY TYPE:
734
ADDRESS:8001 KELOK WAYTELEPHONE:
(925) 673-5442
CITY:CLAYTONSTATE: CAZIP CODE:
94517
CAPACITY:4CENSUS: 4DATE:
04/22/2022
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Melizza Cortez, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Resident sustained a stage 4 pressure ulcer while in care
Resident wound care logs are incomplete
Resident wound care needs were not met
INVESTIGATION FINDINGS:
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On, 4/22/2022 at around 10:45AM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to deliver findings for the above allegations. LPA met with S2, explained the purpose of the visit. LPA called Melizza Cortez to inform her purpose of the visit. At around 11:15AM Administrator arrived at the facility.


Personal Rights - Resident sustained a stage 4 pressure ulcer while in care
Personal Rights - Resident wound care needs were not met

...Continued LIC9099C...


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
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 4
Control Number 15-AS-20211208153427
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: WOODBRIDGE CLAYTON
FACILITY NUMBER: 079200609
VISIT DATE: 04/22/2022
NARRATIVE
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The Department has investigated the above allegations. Based on the Department's observations, interviews conducted, and records review, facility failed to provide adequate care to C1 resulting in a stage 4 pressure wound. C1 requires assistance with toileting needs and risk for pressure ulcer. C1 was admitted at the facility on 06/08/2021 with stage two pressure sore, on November 25, 2021 C1 was sent out to the hospital and was diagnosed with stage 4 pressure wound. Documents review and Administrator claims that C1 refused wound care, however based on Medication Administrator Record (MAR) on November 2021 , licensed staff signed MAR every day that wound care is being performed to C1, there is only one documentation from progress note dated 11/5/2021 that C1 refused wound care from licensed staff.

Allegation: Resident wound care logs are incomplete

Based on interview and records review, facility did not properly document severity of wound, facility also did not properly identify the wound to be pressure injury.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

A formal meeting will be scheduled at a later time.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099 D.

Exit interview conducted and a copy of Appeal Rights provided to Melizza Cortez.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20211208153427
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: WOODBRIDGE CLAYTON
FACILITY NUMBER: 079200609
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/25/2022
Section Cited
CCR
80072(a)(2)
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80072 (a)(2) Personal Rights (a)Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement was not met as evidenced by:
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By POC due date, administrator agrees to conduct in-service staff retraining regarding the regulation cited will submit to CCLD copy of completed staff retraining.
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Based on the Department's investigation, facility failed to provide sufficient care to C1 which resulted to C1 developing stage 4 pressure wound. C1 was hospitalized for treatment of right ischium stage IV and left ischium stage three was later discharged to a skilled nursing facility.
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Immediate civil penalty of $500 assessed during visit.

Formal meeting will be scheduled at a later time.
Type A
04/25/2022
Section Cited
CCR
80078(a)
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80078(a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.

This requirement was not met as evidenced by:
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By POC due date, administrator agrees to conduct in-service staff retraining on proper care and supervision of residents and will submit to CCLD copy of completed staff retraining.
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Based on records review and interview, the licensee did not comply with Regulation. Staff admitted that they were unaware that home health nurse stopped providing wound care, staff stated C1 denied facility staff to access the information from home health, however when facility staff noticed that home health was not visiting, staff provided the Department conflicted statements on what actions they took to reinstate home health/wound care to C1.
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Formal meeting will be scheduled at a later time.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20211208153427
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: WOODBRIDGE CLAYTON
FACILITY NUMBER: 079200609
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/25/2022
Section Cited
CCR
80092.9(a)(5)
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A licensee of an adult CCF may accept or retain a client who has a serious wound if all of the following conditions are met: (5) The licensee ensures that all aspects of care performed by the licensed professional and facility staff are documented in the client's file.
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By POC due date, administrator agrees to conduct in-service staff retraining on the regulation cited and submit copy of training with attendees’ names and signatures.
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This requirement was not met as evidenced by:

Based on records review and interview, the licensee did not comply with Regulation. Facility did not properly document severity of wound, facility also did not properly identify the wound to be pressure injury.
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Formal meeting will be scheduled at a later time.
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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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Leslie Ibo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4