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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201008
Report Date: 10/05/2021
Date Signed: 11/23/2021 03:41:11 PM



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
05/07/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210507162321
FACILITY NAME:TEMESCAL RESIDENTIAL CARE HOME CORP.FACILITY NUMBER:
079201008
ADMINISTRATOR:MELANIO, ANDRES JR JAGARAPFACILITY TYPE:
740
ADDRESS:4580 TEMESCAL COURTTELEPHONE:
(925) 813-5700
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 6DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Andres "Jay" Melanio, AdministratorTIME COMPLETED:
07:10 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
Facility staff did not ensure that resident maintained mobility
Facility did not notify responsible party of change in resident's condition
INVESTIGATION FINDINGS:
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This report is an AMENDMENT that supersedes an original 9099 report dated 10/5/21.

On 10/22/21 at 4PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent complaint visit and met with administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Resident sustained pressure injuries while in care
Investigation finding: Substantiated
Review of records show that R1 moved into the facility on 12/14/20 from a Skilled Nursing Facility. SNF documents do not illustrate R1 having any pressure injuries at discharge. On 12/15/20 R1 was transferred to hospital for an unrelated condition, and no pressure injuries were documented. On 12/30/20, start of home health care assessment commenced and R1 was observed with no pressure injuries. On 01/15/21, during a Physical Therapy visit, facility staff reported R1 had developed pressure injuries while in care. The facility stated having knowledge of a sacral pressure sore but did not seek immediate assistance from home health care. The PT home health records document that the PT found a stage 2 pressure ulcer at the sacrum (confirmed by Skilled Nursing), an unstageable pressure ulcer at the left heel and redness at the right heel. It was further found that between 12/18/20 and 12/30/20 the facility had not been repositioning R1. Based on interviews and record reviews, staff failed to provide appropriate care to R1 resulting in sustaining pressure injuries. The preponderance of evidence has been met. Therefore, this allegation is substantiated.


Continued on next page, LIC 9099-C

A
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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 5
Control Number 15-AS-20210507162321
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
VISIT DATE: 10/05/2021
NARRATIVE
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This report is an AMENDMENT that supersedes an original 9099 report dated 10/5/21

Allegation: Facility staff did not ensure that resident maintain mobility
Investigation Finding: Substantiated
During investigation, staff admitted that R1 was not repositioned into a wheelchair between 12/18/2020 and 12/30/2020 and that he stayed in bed throughout the day, due to resistance by the resident for repositioning. The staff stated a decision to have R1 seen by a Physical Therapist for mobility maintenance, however, the facility failed to seek immediate medical assistance from a Physical Therapist and R1 was not seen by the PT until 12/30/21. The preponderance of evidence has been met. Thus, this allegation is substantiated.

Allegation: Facility did not notify responsible party of change in resident's condition
Based on interviews, home health care was not actively sought by staff on R1 when first admitted at the facility on 12/14/20. R1's authorized representative was not informed that home health care was not being provided to R1 from 12/14/20 to 12/30/20.

Based on 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. See citations on the attached LIC. 9099D and civil penalty assessed on LIC 421IM.

Deficiencies are 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20210507162321
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/29/2021
Section Cited
CCR
87468.2(a)(4)
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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.
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Civil penalty of $500 assessed during visit.

Administrator agreed to re-train staff on proper care and supervision of residents by an accredited vendor
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This requirement was not met as evidenced by R1 sustaining pressure injuries while in care which posed a potential health & safety risk to resident in care
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and submit retraining certification of staff to CCLD on or before POC due date.
Type B
10/29/2021
Section Cited
CCR
87705(c)(3)(A)
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Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living.
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Administrator agreed to submit to CCLD on or before POC due date staff re-training certifications by an accredited vendor on proper care and supervision of residents.
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This requirement was not met as evidenced by: The Department found that facility did not reposition R1 from 12/18/20 to 12/30/20 and did not seek timely medical assistance from a PT or home health which posed a potential health & safety risk to residents 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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
05/07/2021 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20210507162321

FACILITY NAME:TEMESCAL RESIDENTIAL CARE HOME CORP.FACILITY NUMBER:
079201008
ADMINISTRATOR:MELANIO, ANDRES JR JAGARAPFACILITY TYPE:
740
ADDRESS:4580 TEMESCAL COURTTELEPHONE:
(925) 813-5700
CITY:ANTIOCHSTATE: CAZIP CODE:
94531
CAPACITY:6CENSUS: 6DATE:
10/05/2021
UNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Andres "Jay" Melanio, AdministratorTIME COMPLETED:
07:10 PM
ALLEGATION(S):
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2
3
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Resident was not adequately fed while in care
Resident was not allowed visitors
Facility lacked sufficient staff to meet resident's needs
INVESTIGATION FINDINGS:
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On 10/05/21 at 4PM, Licensing Program Analyst (LPA) conducted an unannounced complaint visit to deliver the findings to administrator (ADM). LPA explained the purpose of the visit with ADM.

Allegation: Resident was not adequately fed while in care
Based on interviews and record reviews, R1 had dysphagia and was fed by staff according to doctor's orders of mechanical soft diet. Staff stated they fed R1 three times per day and gave him supplemental protein drinks daily. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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-20210507162321
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: TEMESCAL RESIDENTIAL CARE HOME CORP.
FACILITY NUMBER: 079201008
VISIT DATE: 10/05/2021
NARRATIVE
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Allegation: Resident was not allowed visitors
Review of visitors' logs from 12/2020 until 06/2021 show that R1's authorized representative visited R1 two to three times per week. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

Allegation: Facility lacked sufficient staff to meet resident's needs
Based on record reviews and interviews, two staff worked each shift (AM, PM & NOC shifts) to provide care and supervision to residents. Prior interviews conducted with residents confirm that staff is available at all times to meet their needs. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated.

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

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5