079200827-8-27-2021-15-AS-KHOS-C73L7F-20210921083016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200827
Report Date: 08/27/2021
Date Signed: 08/27/2021 09:51:29 AM

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
05/03/2021 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20210503162616

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: 4	DATE:	08/27/2021
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mauricio David, Caregiver		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Resident developed multiple pressure injuries while in care

Facility staff left resident in soiled clothing for an extended period of time

INVESTIGATION FINDINGS:

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On 08/27/2021 at 9:15AM, Licensing Program Analysts (LPAs) L. Hall and C. Fowler arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPAs met with Caregiver, Mauricio David and explained the purpose for the visit. LPAs spoke with Administrator, Cecilia San Diego-Tomas via telephone. Administrator gave approval for caregiver to sign documents.

This complaint allegation was accepted by the Department’s Investigation Branch (IB) as a full investigation, (IB) report case #CD1521-05062. During the course of the investigation, the Department conducted interviews with resident, staff, and reviewed R1’s medical records, residents’ records, and staff schedule.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

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-20210503162616

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: 08/27/2021

NARRATIVE

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Continued from LIC9099.

The Department investigated the above allegations and found R1 was living at the facility for less than a month. Intake documents stated R1 moved into facility with preexisting deep tissue injury to the right heel and pressure 2 ulcer on the sacrum. Documents indicated Home Health visited on 4/6/2021, 4/20/2021, 4/23/2021 and completed a head-to-toe assessment for each visit and did not note new pressure sores. Investigation also indicated that R1 was living with family before moving into Loving Hands, and the sores could have reopened under his family’s care. R1 stated during Interview that he felt well taken care of and cleaned regularly.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2021

LIC9099 (FAS) - (06/04)

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