079200827-9-3-2020-15-AS-KHOS-BUKNSH-20201020104310

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200827
Report Date: 09/03/2020
Date Signed: 09/03/2020 04:11:11 PM

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
08/18/2020 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200818155107

FACILITY NAME:	LOVING HANDS CARE HOME LLC		FACILITY NUMBER:	079200827
ADMINISTRATOR:	SAN DIEGO-TOMAS, CECILIA		FACILITY TYPE:	740
ADDRESS:	748 VAQUEROS AVE		TELEPHONE:	(510) 245-3738
CITY:	RODEO	STATE: CA	ZIP CODE:	94572
CAPACITY:	6	CENSUS: 5	DATE:	09/03/2020
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Cecilia San Diego-Tomas		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Personal Rights - Resident is not allowed visitors

INVESTIGATION FINDINGS:

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On this day, LPA Luisa Fontanilla conducted a televisit via Facetime to deliver findings on the above allegation and spoke with Administrator Cecilia San Diego-Tomas. LPA explained to the Administrator that this televisit is being conducted in connection with the shelter in place order of the governor and telework directive by management.

On 8/21/2020, LPA initiated the 10-day investigation. On the same day, LPA interviewed the Administrator and R1’s daughter. LPA interviewed R1’s nurse on 8/19/2020. R1’s records were requested and reviewed.

Based on interviews conducted and records reviewed, R1 is currently under the care of a hospice agency. R1’s daughter was not allowed by the facility staff to visit. R1’s daughter states that she has been observing safety precautions so she can be allowed to visit R1, hold her hand and talk to her at the facility.

continuation on Lic 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020

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-20200818155107

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: LOVING HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
	VISIT DATE: 09/03/2020

NARRATIVE

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However, facility still refused to let her visit. Administrator confirmed with LPA that she has not allowed any visitation since March 2020. Administrator stated on 8/21/2020 that she is aware of guidelines outlined in PIN 20-23 ASC issued in June 2020 in regards to end of life visitation.
However, despite knowing the guidelines, Administrator states that she did not and will not allow end of life visitation . Therefore, the above allegation is substantiated.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22 Sec 87468.1(11) Personal Rights of Residents in All Facilities, is being cited on the attached LIC 9099D.
Failure to correct deficiency by POC date may result in civil penalties.

Exit interview conducted with Administrator; Appeal Rights was provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200818155107

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: LOVING HANDS CARE HOME LLC	FACILITY NUMBER: 079200827
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/03/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/04/2020 Section Cited CCR 87468.1(11)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities To have their visitors, including ombudspersons and advocacy representatives, permitted to visit privately during reasonable hours and without prior notice, provided that the rights of other residents are not infringed upon.	1 2 3 4 5 6 7	By POC date, Administrator will review guidelines on Visitation provided in PIN 20-23 ASC and allow visitation in accordance. Administrator will self-certify that she reviewed PIN20-23 ASC and will develop and implement a plan for allowing end of life visitation to the facility and submit plan to CCL by POC date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews conducted, Administrator confirmed that she did not and will not allow visitors to the facility despite guidelines on end of life visitation issued by CCL in June 2020 which poses a potential risk to the health and safety of the resident under care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2020

LIC9099 (FAS) - (06/04)

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