079200913-3-7-2025-15-AS-BFOG-DEULNN-20250317085435

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200913
Report Date: 03/07/2025
Date Signed: 03/07/2025 01:29:34 PM

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
02/13/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250213093047

FACILITY NAME:	KALYNNA HOME		FACILITY NUMBER:	079200913
ADMINISTRATOR:	IKHARO, RAUFAT		FACILITY TYPE:	740
ADDRESS:	5366 THUNDERBIRD COURT		TELEPHONE:	(925) 303-3853
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 5	DATE:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Raufat Ikharo, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff did not ensure resident’s wound care needs were met resulting in hospitalization

INVESTIGATION FINDINGS:

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On 03/07/25 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit to deliver the findings of the allegations. LPA explained the purpose of the visit with Administrator (ADM).

During investigation, the department obtained the following documents from administrator – personnel record (LIC500) residents’ roster, admission agreement, physician's report, preplacement appraisal, hospice care plan, emergency information, responsible party (POA) information, home heath reports. Health & safety check conducted see LIC 809 dated 02/13/25.

Continued on next page, LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

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 5

Control Number 15-AS-20250213093047

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: KALYNNA HOME	FACILITY NUMBER: 079200913
	VISIT DATE: 03/07/2025

NARRATIVE

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ALLEGATION: Staff did not ensure resident’s wound care needs were met resulting in hospitalization
INVESTIGATION FINDING: Substantiated
During investigation, the department conducted interviews of facility staff (ADM, S1) and third party witness (W1) and reviewed resident’s (R1) documents. Review of R1’s records showed she was first admitted at Ambassador Care Home on 07/30/2019 when she was 88 years old. ADM stated R1 was verbal, ambulatory and required minimal assistance with activities of daily living such as personal hygiene, toileting, dressing, grooming, meals, medications, doctors’ appointments. On October 2023, R1’s (92 years old) health gradually declined with very poor appetite, severe weakness and weight loss. R1 was placed under hospice care by responsible party (POA) and primary care physician (PCP). She remained stable and was discharged from hospice on April 2024 with quarterly visits from her PCP, nurse (W1) and home health care team. W1 stated she was the primary care nurse for R1, visited and checked on her once a month for the past two years and worked with the home health team to care for R1. She noticed a new stage 2 pressure injury on R1’s coccyx on 07/26/24. She reminded staff to reposition R1 every 2 hours daily as prescribed. However, W1 stated she noticed that there was only one staff caring for 5 residents during her unannounced visits. W1 also stated R1 was not turned or repositioned every 2 hours because R1 was found by home health nurse in the same position from last visit. On 12/04/24, R1 was sent to the hospital ER because her wound had developed an odor. R1's was diagnosed with stage 3 coccyx pressure injury and a wound vacuum was prescribed with home health visits 3X per week. On 01/22/25, R1 was again sent to the hospital due to declining health. R1 was diagnosed with stage 4 coccyx injury and infection. Based on observations and interviews which were conducted and record review(s), the department has substantiated the allegation that staff did not ensure resident’s wound care needs were met resulting in hospitalization. The preponderance of evidence standard has been met. Therefore, the above allegation was found to be substantiated.

Immediate civil penalty of $500 assessed during visit for staff failing to provide adequate care and supervision to resident resulting in resident being hospitalized twice while in care.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20250213093047

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: KALYNNA HOME	FACILITY NUMBER: 079200913
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/07/2025 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.	1 2 3 4 5 6 7	Immediate civil penalty of $500 assessed during visit.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff failing to provide adequate care and supervision to resident resulting in resident being hospitalized twice which posed an immediate health & safety risk to residents in 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/13/2025 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20250213093047

FACILITY NAME:	KALYNNA HOME		FACILITY NUMBER:	079200913
ADMINISTRATOR:	IKHARO, RAUFAT		FACILITY TYPE:	740
ADDRESS:	5366 THUNDERBIRD COURT		TELEPHONE:	(925) 303-3853
CITY:	ANTIOCH	STATE: CA	ZIP CODE:	94531
CAPACITY:	6	CENSUS: 5	DATE:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Raufat Ikharo, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff did not provide proper food service to resident in care

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20250213093047

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: KALYNNA HOME	FACILITY NUMBER: 079200913
	VISIT DATE: 03/07/2025

NARRATIVE

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Allegation: Staff did not provide proper food service to resident in care
Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM), third part witness (W1) and reviewed R1’ documents. Review of R1’ documents showed that on 10/2023, R1 was placed under hospice care by her responsible party (POA) and primary care physician (PCP) due to very poor appetite, severe weakness and weight loss. ADM stated R1 remained stable with hospice and was later discharged from hospice in April 2024. ADM stated that R1’s nutritionist placed her on ensure with protein supplement to help with wound healing. Home Health care team managed R1’s wound with a wound vacuum placed on the wound and visited R1 three times per week to help with wound healing. R1 lost a lot of weight because she refused to eat her meals and had no interest in eating or drinking. As a result, her wound was not healing due to her very poor nutritional intake. On 12/05/24, staff sent R1 to the hospital because her wound had developed an odor, would not heal, continued loss of appetite and severe weight loss. ADM stated R1’s food intake remained very poor despite staff physically putting food and liquid into her mouth. Although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff did not provide proper food service to resident in care was found to be unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 5