079200743-6-23-2022-15-AS-KHOS-CG2JJ6-20220705070459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200743
Report Date: 06/23/2022
Date Signed: 06/23/2022 01:43:00 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
01/05/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220105161401

FACILITY NAME:	ANGEL WINGS CARE HOME II		FACILITY NUMBER:	079200743
ADMINISTRATOR:	SAMIA, VILMA		FACILITY TYPE:	740
ADDRESS:	1921 BLUE MOUNTAIN COURT		TELEPHONE:	(510) 329-4926
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 6	DATE:	06/23/2022
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Vilma Samia, administrator		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Resident was not checked on or turned for extended period of time
Residents care needs are not being met

INVESTIGATION FINDINGS:

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On 06/23/22 at 12:20PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident was not checked on or turned for extended period of time
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, resident (R1) was admitted at the facility on 08/31/21. Review of R1’s appraisal report shows him as ambulatory (able to walk without a walker). On 12/30/21, staff called 911 because staff observed R1 had a fever and developing blisters on both his heels. Review of hospital discharge report show R1 was treated for blisters on his heels and released back to the facility on 12/31/21 with wound care instructions. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

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-20220105161401

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: ANGEL WINGS CARE HOME II	FACILITY NUMBER: 079200743
	VISIT DATE: 06/23/2022

NARRATIVE

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On 01/03/22, staff called medical advice nurse and requested a regular home health nurse to follow up for wound management. S1 left a message with R1’s primary care physician and authorized representative for after emergency room visit. On 01/04/22, staff called 911 again because R1 had increased cough, chills and fever. Staff observed R1 started having difficulty moving around and his mobility has sharply decreased. Staff stated that they observed little blisters forming throughout his body despite all the interventions that they implemented by elevating his heels, frequent repositioning and diaper changes. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Resident’s care needs are not being met
Investigation Finding: UNSUBSTANTIATED
Based on interviews and record reviews, LPA's review of incident report dated 12/23/21 show staff observed R1 developed a fever and forming blisters on both heels. Staff called 911 on 12/30/21 and R1 was treated at the hospital and released back to the facility. Staff followed wound care instructions, treated the blisters, bandaged them and elevated R1’s legs . Staff also noticed that R1 started to develop a bed sore on his butt and contacted his primary care physician to request a home health nurse for R1. Staff stated R1 started to develop more bed sores at his hips on 01/03/22 despite staff turning him every 2 hours, assisting with his walks and hydrating him. Staff called 911 again on 01/04/22 and was taken to the hospital for evaluation and treatment. R1 was treated for fever and increasing bed sores. He was later admitted at a skilled nursing facility from the hospital. On 02/11/22, R1 returned back to the facility under hospice care. Other residents at the facility stated their care needs are being met by staff. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2022

LIC9099 (FAS) - (06/04)

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