079201006-6-24-2022-15-AS-KHOS-CG2JQG-20220705071507

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201006
Report Date: 06/24/2022
Date Signed: 06/24/2022 02:03:17 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
06/17/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220617083613

FACILITY NAME:	VIAMONTE AT WALNUT CREEK		FACILITY NUMBER:	079201006
ADMINISTRATOR:	MELODY MITCHELL ALLEN		FACILITY TYPE:	741
ADDRESS:	2801 SHADELANDS DRIVE		TELEPHONE:	(925) 954-2600
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	300	CENSUS: 7	DATE:	06/24/2022
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Christine Jean, Director of Wellness		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff inappropriately handled resident resulting in bruising

INVESTIGATION FINDINGS:

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On 06/24/22 at 12:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint investigation, met with Director of Wellness (DW), gathered information relevant to the allegation and delivered the investigation finding. LPA explained the purpose of the visit with DW.

LPA reviewed the non audio video camera footage captured on 06/13/22 with DW. LPA observed resident (R1) mistakenly going into apartment # 354 instead of apartment # 355 which is right next door to his unit. R1 was followed closely by staff (S2) who was trying to redirect R1 to his apartment # 355. An exchange of words was observed between R1 and S2 which caused R1 to slightly shove S2.

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: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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 3

Control Number 15-AS-20220617083613

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: VIAMONTE AT WALNUT CREEK	FACILITY NUMBER: 079201006
	VISIT DATE: 06/24/2022

NARRATIVE

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LPA observed S2 physically attack R1 and tackle him to the ground. DW stated at that time S2 was yelling for the nurse to help. The nurse and R1's personal trainer showed up right away. R1 was safely redirected by his personal caregiver and was able to calm him down. The nurse on duty completed a wellness check (pain & discomfort), found no bruising on R1's body. R1 stated he was not in any pain or discomfort.

Based on LPA’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) was found to be substantiated.

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 via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20220617083613

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: VIAMONTE AT WALNUT CREEK	FACILITY NUMBER: 079201006
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/24/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons	1 2 3 4 5 6 7	Director of Wellness corrected deficiency during visit. Staff retraining on how to properly care for Dementia residents was conducted 06/21/22 conducted by
	8 9 10 11 12 13 14	This requirement was not met as evidenced by S2 tackling R1 to the ground during an incident on 06/13/22 which posed an immediate risk to resident in care	8 9 10 11 12 13 14	Dementia Care Consulting Group. Copy of completed training on Dementia Care was emailed to LPA during visit.
	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: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC9099 (FAS) - (06/04)

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