079200734-1-26-2023-15-AS-BFOG-CQ529R-20230320171223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200734
Report Date: 01/26/2023
Date Signed: 01/26/2023 10:39:27 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
09/07/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20220907140306

FACILITY NAME:	BAY CARE ASSISTED LIVING LLC		FACILITY NUMBER:	079200734
ADMINISTRATOR:	ONYEAGOCHA, ROSE C		FACILITY TYPE:	740
ADDRESS:	2352 SHANNON AVE		TELEPHONE:	(510) 964-1669
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	6	CENSUS: 5	DATE:	01/26/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Gloria Amaya, Caregiver		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Questionable death
Staff did not ensure resident had sufficient liquids
Staff dispensed wrong dosage of medications
Facility serves low quality food
Facility staff slapped resident

INVESTIGATION FINDINGS:

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On 1/26/2023 at 9:45AM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Caregiver, Gloria Amaya and explained the reason for the visit.

During the course of the investigation the Department interviewed 3 staff, 1 family witness and Reporting Party (RP); and obtained & reviewed the following documents: facility and staff roster, resident status change form, physician's report, appraisal needs and service plan, Medication Administration Record (MAR), Centrally Stored Medication and Destruction Record (CSMDR), facility menu, caregiver work schedule, Certificate of Death and Hospice Case notes.

Questionable Death.
While the RP alleged that R1 passed away due to severe dehydration, based on information obtained from residents’ certificate of death it was found that R1s resident’s cause of death was from an unrelated, documented condition. The Department obtained records indicating that R1 was receiving hospice and comfort care only. W1 reported that W1 and R1 had agreed upon comfort care.

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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-20220907140306

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: BAY CARE ASSISTED LIVING LLC	FACILITY NUMBER: 079200734
	VISIT DATE: 01/26/2023

NARRATIVE

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Continue from LIC9099

Staff did not ensure resident had sufficient liquids.

The Hospice care plan was reviewed, and it was found that hospice advised the facility to honor R1s refusal of food & liquid. S1 reported (corroborated by W1) that the facility was providing liquids such as, juice, coffee, water and milk. Fresh juice was provided by family. W1 also stated that R1 would take small sips of liquid as much as she could tolerate due to her condition.

Staff dispensed wrong dosage of medications.

R1’s medication administration record indicated all medication was given as prescribed. S1 reported that R1 was never given an incorrect dose of medication. W1 reported having been with R1 throughout the time R1 was at the facility, and that there were no medication errors. Further, W1 reported that W2 was also present during medication rounds and reviewed with the hospice nurse R1s medications when administered. S2 and S3 (who had assisted R1) denied any knowledge of a medication error.

Facility serves low quality food.

A tour of the facility was conducted and the facility was observed to have a minimum of 2-day perishable and 7-day non-perishable food supply, including fresh fruits and vegetables, cereals, bread, juice, milk, water, coffee, and meats. The facility menu which indicates a variety of meals are planned. W1 observed and reported having no issues with the quantity and quality of the food, stating that R1 could consume little food and liquid – as stated in the hospice care plan. S3 reported that all meals were provided to R1 but that she could tolerate little food and drink. S3 also reported that W1 also attempted to food R1.

Continue on LIC9099C

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220907140306

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: BAY CARE ASSISTED LIVING LLC	FACILITY NUMBER: 079200734
	VISIT DATE: 01/26/2023

NARRATIVE

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Continue from LIC9099C

Facility Staff slapped resident.

W1 which reported being by R1’s side the entire stay at the facility and that no caregiver had ever slapped R1. W1 stated that 2 caregivers took good care of R1. The two caregivers that assisted R1 were interviewed: S2 reported never having slapped or witnessed anyone slap R1. S2 reported that R1 was served all meals and liquids but she did not eat because she was weak and fragile. S3 reported that she did not slap or witness any coworkers slap R1.

Based upon records review, interviews conducted, and observations made, the Department has investigated the above allegations and found that they are Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of this report provided

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC9099 (FAS) - (06/04)

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