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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200882
Report Date: 08/16/2022
Date Signed: 08/16/2022 12:44:02 PM

Unfounded


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
05/11/2021 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20210511161656
FACILITY NAME:CHERISH CARE HOME INC.FACILITY NUMBER:
079200882
ADMINISTRATOR:OKEIGWE, OGEDIFACILITY TYPE:
740
ADDRESS:15 DICKSON LANETELEPHONE:
(925) 250-3044
CITY:MARTINEZSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: DATE:
08/16/2022
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Kimarley Whyte/StaffTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Resident (R1) sustained pressure injury while in care.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Delmundo arrived unannounced to deliver the complaint findings for the above allegation. LPA met with Kimarley Whyte, and informed the reason for the visit.

It was alleged that after 3 weeks of being admitted to the facility, resident (R1) developed stage IV pressure injury on the back that was septic.

During the course of investigation, the Department obtained and reviewed R1’s medical records, and conducted interviews.


.....continued next page (9099C)
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
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 2
Control Number 15-AS-20210511161656
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: CHERISH CARE HOME INC.
FACILITY NUMBER: 079200882
VISIT DATE: 08/16/2022
NARRATIVE
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Medical records showed that prior to admission to the facility, R1 had a fall in R1’s home with ongoing pain. R1 reported sudden onset of bilateral leg weakness where R1 was found with a new T11 fracture. R1 had a custom Thoracic Lumbar Sacral Orthosis (TLSO) brace that R1 was directed to wear any time R1 was not laying in bed. R1’s family member (FM) stated that R1 fell while R1 was living in R1’s home and R1’s vertebrae were shattered and had a surgery. FM stated R1 was given a brace to be worn all day and from rehab, R1 moved to the facility where R1 was seen by Home Health who provided wound care. Social Worker (SW) stated that R1 was admitted to the emergency, and after being seen by the doctor, was determined that R1 was septic due to a stage IV on R1’s lumbar spine. It was also determined that the TLSO brace was pressing on the area causing the pressure injury, and the hospital staff were sure that the pressure injury was caused by the brace.

S1 and S2 stated that R1 wore the brace and only removed when sleeping which corroborated with R1’s statement. R1 indicated that the injury was not caused by neglect by staff but by the brace. Residents (R2 and R3) were interviewed who both confirmed that R1 had been wearing the brace which looked uncomfortable but R1 never complained of pain.

Based upon records review and interviews, the allegation is unfounded. A finding that the complaint is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore, the complaint is dismissed.

Exit interview conducted and a copy of report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Alicia DelmundoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2