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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 10/06/2023
Date Signed: 10/06/2023 01:28:02 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
08/08/2023 and conducted by Evaluator Paris Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230808160115
FACILITY NAME:A OHANA HOME FOR SENIORS, LLCFACILITY NUMBER:
079200924
ADMINISTRATOR:MALEKAMU, MARYFACILITY TYPE:
740
ADDRESS:1841 FLORENCE LNTELEPHONE:
(925) 698-1736
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: 3DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Mary Malekamu, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff did not ensure that resident’s bedrails were in place, resulting in resident sustaining a fall
Staff dispensed incorrect medication to resident
Staff did not ensure that resident took the medication that was dispensed to them
INVESTIGATION FINDINGS:
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On 10/06/2023 at 12:10 PM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. Administrator arrived at1:00 PM. LPA met with Administrator, Mary Malekamu and explain the purpose of the visit

During the course of the investigation the Department interviewed residents and staff and obtained documents. Documents including but not limited to: Staff roster with contact information, staff schedule for June and July, resident roster, resident care plans, resident progress notes, MARS and LIC 622 for June and July, and recent Physicians report.


Report continues on 9099 C

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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-20230808160115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: A OHANA HOME FOR SENIORS, LLC
FACILITY NUMBER: 079200924
VISIT DATE: 10/06/2023
NARRATIVE
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It was alleged that Staff did not ensure that resident’s bedrails were in place, resulting in resident sustaining a fall.

Based on interview with resident (R1), he kept his bedrails up most of the time. Based on interview with home health nurse, when they would visit the resident, they observed R1 bedrails to be up.

It was alleged that Staff dispensed incorrect medication to resident.

Based on interviews with residents (R2, R3, R4 and R5), residents stated that they have had no issues with staff dispensing their medication incorrectly and/or not receiving their medication. R4 stated that facility staff knows what she needs and regulates her. Based on interview with R1, there was one incident where staff offered R1 the wrong medication, once R1 brought it to staff attention, they dispensed the correct medication to him. R1 stated that other than this one incident, all other medication has been dispensed with no issues.

It was alleged that Staff did not ensure that resident took the medication that was dispensed to them.

Based on interview with R1 home health nurse, they once observed medication on the floor in the resident’s room. Home health nurse asked resident about it and was informed that the medication was dropped by accident and staff gave them another pill to take. Based on interview with R1, there has been no issues with them not talking their medications.

Although the allegations may have happened or are valid, there are 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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
08/08/2023 and conducted by Evaluator Paris Watson
COMPLAINT CONTROL NUMBER: 15-AS-20230808160115

FACILITY NAME:A OHANA HOME FOR SENIORS, LLCFACILITY NUMBER:
079200924
ADMINISTRATOR:MALEKAMU, MARYFACILITY TYPE:
740
ADDRESS:1841 FLORENCE LNTELEPHONE:
(925) 698-1736
CITY:CONCORDSTATE: CAZIP CODE:
94520
CAPACITY:6CENSUS: DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Mary Malekamu, AdministratorTIME COMPLETED:
01:40 PM
ALLEGATION(S):
1
2
3
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Staff did not respond to resident’s calls for help after resident sustained a fall
INVESTIGATION FINDINGS:
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On 10/06/2023 at 12:10 PM, Licensing Program Analyst P Watson arrived unannounced deliver findings for the above allegations. Administrator arrived at 1:00 PM. LPA met with Administrator, Mary Malekamu and explain the purpose of the visit

During the course of the investigation the Department interviewed residents and staff and obtained documents. Documents including but not limited to: Staff roster with contact information, staff schedule for June and July, resident roster, resident care plans, resident progress notes, MARS and LIC 622 for June and July, and recent Physicians report.


Report continues on 9099 C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230808160115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: A OHANA HOME FOR SENIORS, LLC
FACILITY NUMBER: 079200924
VISIT DATE: 10/06/2023
NARRATIVE
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This is an amended report from 10/06/2023.

It was alleged that Staff did not respond to resident’s calls for help after resident sustained a fall

Based on interview with (R1), R1 went about 6-8 hours before they were helped back into bed. R1 was unable to reach their call button but verbally called out for help. Live-in Staff were unable to hear R1's verbal call. Once R1 was assisted back to bed he was okay. R1 stated they did not sustain any injuries.

Based on LPA interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) is being cited on the attached LIC 9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230808160115
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: A OHANA HOME FOR SENIORS, LLC
FACILITY NUMBER: 079200924
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/07/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4)
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall..(4)To care, supervision, and services that meet their individual needs ...
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Adminstrator will review regulation with staff and think of alternative methods that can be used for fall risk residents. Administrator will submit a self certification and list of alternatives to CCL by POC date
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Based on interview, the licensee did respond to R1's verbal call for help after they sustained a fall which poses/posed an immediate Health, Safety or Personal Rights risk to persons in care
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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: Yvonne Flores-LariosTELEPHONE: (510) 725-7926
LICENSING EVALUATOR NAME: Paris WatsonTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5