079200924-12-30-2021-15-AS-KHOS-CAEJSY-20220106061907

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200924
Report Date: 12/30/2021
Date Signed: 12/30/2021 11:00:41 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
09/29/2020 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20200929141116

FACILITY NAME:	A OHANA HOME FOR SENIORS, LLC		FACILITY NUMBER:	079200924
ADMINISTRATOR:	MALEKAMU, MARY		FACILITY TYPE:	740
ADDRESS:	1841 FLORENCE LN		TELEPHONE:	(925) 698-1736
CITY:	CONCORD	STATE: CA	ZIP CODE:	94520
CAPACITY:	6	CENSUS: 4	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rose Malekamu, administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an injury while in care
Facility did not provide Ombudsman with roster of residents
Facility failed to report resident injury

INVESTIGATION FINDINGS:

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On 12/30/21 at 9:30AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent complaint visit with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Allegation: Resident sustained an injury while in care
Investigation Finding: SUBSTANTIATED
During visit, neutral witness (W1) observed resident (R1) at the facility with a contusion below his right knee appearing to be in pain. Staff told W1 that they gave R1 Tylenol for his pain and stated R1 was on hospice with A Plus Hospice. Staff told W1 that they did not know where or when R1 sustained the knee injury. On 12/30/21, Administrator stated she remembered W1 visiting R1 at the facility and talking to him regarding his injured knee. Based on LPA’s interviews and record reviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

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: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

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 4

Control Number 15-AS-20200929141116

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: A OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
	VISIT DATE: 12/30/2021

NARRATIVE

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Allegation: Facility did not provide Ombudsman with roster of residents
Investigation Finding: SUBSTANTIATED
During visit, Administrator confirmed with LPA that facility staff failed to provide residents’ roster to Ombudsman on 09/28/21 upon request because there was none to give (LIC 9020). Administrator stated they did not have a completed resident roster (LIC 9020) during that time. The preponderance of evidence standard has been met. Therefore, this allegation is substantiated.

Allegation: Facility failed to report resident injury
Investigation Finding: SUBSTANTIATED
During visit, administrator confirmed with LPA that they did not submit an incident report regarding R1’s injury at that time. LPA observed no incident report was received at CCLD regarding this event from the facility. The preponderance of evidence standard has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099Ds. Failure to submit proof of corrections (POC) by plan of correction due dates 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 via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20200929141116

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: A OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2022 Section Cited CCR 87633(d)	1 2 3 4 5 6 7	Hospice Care of Terminally ill residents (d) The licensee shall ensure that the hospice care plan is current, accurately matches the services being provided, and that the client’s care needs are being met at all times.	1 2 3 4 5 6 7	By POC due date, administrator agreed to submit to CCLD a self-certification that staff has read, understood and will comply with Section 87633 regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by resident sustaining injury while in care which posed a potential health & safety risk to resident in care	8 9 10 11 12 13 14
Type B 01/17/2022 Section Cited CCR 87506(d)	1 2 3 4 5 6 7	Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.	1 2 3 4 5 6 7	By POC due date, administrator agreed to submit to CCLD a self-certification that staff has read, understood and will comply with Section 87506 regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by missing resident roster (LIC 9020) for inspection which posed a potential health & safety risk to residents in care.	8 9 10 11 12 13 14

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: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20200929141116

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: A OHANA HOME FOR SENIORS, LLC	FACILITY NUMBER: 079200924
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/17/2022 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements (a) (1) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events…	1 2 3 4 5 6 7	By POC due date, administrator agreed to submit to CCLD a self-certification that staff has read, understood and will comply with Section 87211 regulations.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by failure of staff to submit incident report to CCLD which posed a potential 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: 12/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4