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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200784
Report Date: 08/22/2023
Date Signed: 08/22/2023 11:11:22 AM

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
06/26/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230626112336
FACILITY NAME:LAFAYETTE GARDENSFACILITY NUMBER:
079200784
ADMINISTRATOR:SAXENA, MEERANFACILITY TYPE:
740
ADDRESS:3486 MONROE AVENUETELEPHONE:
(408) 623-2859
CITY:LAFAYETTESTATE: CAZIP CODE:
94549
CAPACITY:6CENSUS: 6DATE:
08/22/2023
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Meeran SaxenaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained unexplained injuries while in care.
Staff did not inform resident's responsible party of change of
health status.
Staff did not seek medical attention to resident.
INVESTIGATION FINDINGS:
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On 8/16/2023, Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to deliver findings on the above allegations and met with Meeran Saxena. LPA explained to Saxena the purpose of the visit.

On 6/20/2023, LPA conducted an initial investigation, obtained records and conducted interviews. On the same day, LPA conducted a pre-investigation with Reporting Party (RP).

Resident sustained unexplained injuries while in care.
Staff did not inform resident’s responsible party of change of health status.
Staff did not seek medical attention to resident.

Based on records review conducted by LPA, the home health nurse following up on R1 observed R1 experiencing pain in hand in the morning of 6/3/2023.
continuation on Lic 9099C

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
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-20230626112336
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: LAFAYETTE GARDENS
FACILITY NUMBER: 079200784
VISIT DATE: 08/22/2023
NARRATIVE
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The nurse reported R1’s condition to R1’s son. R1’s son then instructed Administrator to send R1 to the hospital to get checked on 6/5/2023. R1 went to a skilled nursing facility upon discharge from the hospital and did not come back to the facility.

R1 moved to the facility on May 1, 2023 and moved out on June 7, 2023.

A review of email conversations between Administrator and R1's son indicate the Administrator informing R1’s son that R1 does not have any fracture. And that the hand is not swollen. The administrator also states the reason could be that R1 was taking some part of the bed and has broken pots in the room. The Administrator states, “In the future, I will make sure the care staff calls you and update you regarding any decline.”

A review of R1’s medical records and photo provided to CCL indicate R1 sustained bruises on both arms and a cut on the left bicep. During the interview with Administrator and Staff 1 (S1), both state R1 did not incur any fall. Administrator and S1 state R1 probably got the bruises and cut when R1 was exhibiting aggressive behavior such as crawling under the bed, throwing pots and trying to pull down picture frames.

Based on record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors.

Based on LPA interviews and record reviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22. Deficiencies are being cited on the attached LIC 9099D.

Exit interview was conducted with Meeran. Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20230626112336
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: LAFAYETTE GARDENS
FACILITY NUMBER: 079200784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/23/2023
Section Cited
CCR
87705(b)(1)
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87705 (b)(1) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:

(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
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The administrator will review facility’s plan of operation regarding procedures for notifying the resident’s physician, family members, or conservator when a resident’s condition or behavior changes. Administrator will submit to CCL self-certification of understanding by POC date
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87705 (b)(1) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:

(1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
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Type B
08/23/2023
Section Cited
CCR
87705(b)(2)
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87705(b)(2) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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The administrator will review all residents Physician’s Reports and update Appraisal Needs and Services Plan addressing resident behaviors such as wandering and aggressive behavior. Administrator will send copies of updated care plan by POC date.
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This requirement is not met as evidenced by:
Based on interviews and record reviews conducted, Resident 1 R1) has a diagnosis of Dementia, is confused/disoriented, has aggressive, wandering and sundowning behaviors. Administrator and facility staff interviewed state R1 was observed crawling under the bed, throwing flowerpots inside the room and pulling down picture frames on the wall.
Despite observing R1’s aggressive behaviors, the facility did not provide safety measures to prevent R1 from sustaining bruises on both arms and a cut on R1’s left biceps which poses an immediate threat to the health and safety of clients under care.
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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20230626112336
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: LAFAYETTE GARDENS
FACILITY NUMBER: 079200784
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/25/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility
(1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents..
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By POC date, Administrator will review all resident files and ensure that all residents are current with medical/dental appointments. Administrator will self-certify completion and send to CCL.
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This requirement is not met as evidenced by:
Based on interviews conducted, staff observed R1 with bruise, agressive, crawling under the bed, breaking pot plants but no medical appointment was arranged which poses a potential risk tohelath and safety of clients under care.
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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.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4