079200787-2-5-2025-15-AS-BFOG-DDRUM5-20250210144144

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200787
Report Date: 02/05/2025
Date Signed: 02/05/2025 05:11:56 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
08/18/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230818151513

FACILITY NAME:	DIANA'S CARE HOME		FACILITY NUMBER:	079200787
ADMINISTRATOR:	REANO-AQUINO, GRACE		FACILITY TYPE:	740
ADDRESS:	27402 MANON AVENUE		TELEPHONE:	(510) 786-9982
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	0	CENSUS: 35	DATE:	02/05/2025
		UNANNOUNCED	TIME BEGAN:	04:45 PM
MET WITH:	Grace Corda Aquino/Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility did not provide sufficient care/supervision resulting to resident (R1) sustaining fractured ribs.

INVESTIGATION FINDINGS:

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At 4:45 pm on this day, 2/05/25, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver the findings for the above allegation. LPA met with Grace Corda Aquino, administrator, and informed the purpose of visit.

During the course of investigation, the Department obtained copies of LIC9020 Register of Facility Clients/Residents, staff schedule and the following residents’ documents: Admission Agreement; LIC601 Identification and Emergency Contact Information; LIC602A Physician's Report; Pre-admission Appraisal; LIC625 Appraisal/Needs and Services Plan; Hospital After Visit Summary; Unusual Incident Reports; facility notes; medical records.

.....continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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-20230818151513

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: DIANA'S CARE HOME	FACILITY NUMBER: 079200787
	VISIT DATE: 02/05/2025

NARRATIVE

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The Department interviewed residents (R1, R2, R3), staff (S1, S2, S3 and administrator) and reporting party (RP) on 9/12/23. The Nurse Practitioner (NP) was also interviewed on 9/13/23 and medical records were reviewed.

R1 stated he needs assistance in transferring. R1 denied ever being abused and falling or getting injured while at the facility. R1 also denied having fracture and stated had only fractured his ribs when shot while serving in the military. The other 2 residents made no disclosures of ever being hurt and mistreated at the facility, having any complaints about the facility staff, and stated never seen any other residents get hurt or mistreated while at the facility.

The four facility staff reported they did not know R1 had fractured ribs or how R1 could have sustained the injuries. They denied R1 ever falling at the facility. They stated R1 requires two person assistance during transfers, and that staff would pick R1 up from underneath R1’s armpits.

Reporting Party (RP) and Nurse Practitioner (NP) both stated they did not know if the injuries R1 sustained are old or new. NP stated the medical records showed the injuries to be sub-acute but not sure, and stated the injuries could be due to infiltration.

Review of medical records showed a right 2nd to 6th rib fractures. Previously, only right 4th and 5th rib fractures were seen. The fractures were noted to be “acute/subacute” fractures.

Based on interviews and records review, the allegation is unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC9099 (FAS) - (06/04)

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