<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200618
Report Date: 11/03/2021
Date Signed: 11/03/2021 09:15:35 AM

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
05/13/2020 and conducted by Evaluator Grace Luk
COMPLAINT CONTROL NUMBER: 15-AS-20200513145242
FACILITY NAME:MACRI'S ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
079200618
ADMINISTRATOR:INGCO, MARIA DFACILITY TYPE:
737
ADDRESS:4680 NEROLY ROADTELEPHONE:
(925) 679-4430
CITY:OAKLEYSTATE: CAZIP CODE:
94561
CAPACITY:4CENSUS: 4DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Anastacio Palancos, AdministratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to staff neglect, client sustained fracture while in care.
Due to staff neglect, client sustained a pressure injury while in care.
Staff failed to seek timely medical care from 5/8/2020, when client fall, until 5/13/2020.
Facility failed to report as required
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/3/2021 at 8:45AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPA met with Administrator, Anastacio Palancos and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, case manager, health providers, and complainant. C1’s medical records and facility file, incident report, and facility’s correspondence with health providers were obtained and reviewed.

On 5/8/2020, when C1 was walking in front of S4 heading to the backyard after dinner, C1 fell and was in a seated position. Interview with staff indicated that C1 had no history of falls and described C1 as mobile and could run. C1 had 1:1 care and supervision before and after the fall incident. S4 sought assistance from other staff immediately after C1 fell. C1’s health providers were notified of the fall and staff have been in communication with them regarding C1’s conditions. C1 was taken to the emergency room (ER) on 5/13/2020. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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 2
Control Number 15-AS-20200513145242
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: MACRI'S ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 079200618
VISIT DATE: 11/03/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
C1 was unable or unwilling to stand after his fall. Staff were able to put C1 on a mat and move the mat inside the facility. Interview with staff revealed that C1 was repositioned every two hours during waking hours. However, C1 would independently move back to original position. When staff asked C1 to get up, C1 refused to get up from the living room floor and go to the room. C1’s health providers were notified of the pressure injury and recommend that C1 should be off the floor. On 5/13/2020, C1 was taken to the ER.

Staff were in routine communication with C1’s health providers who advised the matter was not an emergency, and that it could wait. Record of correspondence with health providers supports staff was in regular contact with C1’s health providers regarding C1’s status. C1 fell on 5/8/2020 and staff immediately communicated the fall to C1’s health providers who advised staff to ice, elevate, and wrap C1’s ankle. Staff communicated with C1’s health providers on 5/9/2020 by sending updated photographs. On 5/11/2020, C1’s health providers responded the bruising was a sign of bleeding from torn ligaments and staff could wait another day so that an x-ray order could be written. Staff informed C1’s health providers that it would be difficult transport C1 and inquired if an x-ray could be done at the facility. Health provides advised an order would be sent to radiology and it wouldn’t hurt the situation to wait a little longer. Staff continued to update health providers with recent photographs of the injury later that evening on 5/11/2020. Health providers indicated it was not an emergency and it was superficial bleeding under the skin from torn soft tissue. On 5/13/2020, health providers recommended staff call 911.

Staff did not report C1’s initial fall that occurred on 5/8/2020. However, staff reported C1’s medical transport on 5/13/2020. Staff provided a copy of the email sent on 5/14/2020 and both incident reports. By providing the incident report to LPA on 5/15/2020, it met the requirement of submitting a written report to the Department.

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

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2