<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201008
Report Date: 11/23/2021
Date Signed: 11/23/2021 03:31:50 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:
11/23/2021
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Ricky Luna, caregiverTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not ensure that resident maintained mobility
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/23/21 at 3PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a subsequent complaint visit and met with caregiver. LPA explained the purpose of the visit with caregiver and administrator (ADM). LPA spoke with ADM on the phone who authorized caregiver to act on her behalf and sign the reports.
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.

Continued on next page, LIC 9099-C
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: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
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 3
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: 11/23/2021
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
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.

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: 11/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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: 11/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/29/2021
Section Cited
CCR
87705(b)(1)
1
2
3
4
5
6
7
In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident’s physician, family members and responsible persons who have requested notification, and conservator, if any, when a resident’s behavior or condition changes.
1
2
3
4
5
6
7
By POC date, administrator will submit to CCLD a self certification that they have read, understood and will comply with Title 22 Section 87705 regarding Care of Persons with Dementia.
8
9
10
11
12
13
14
This requirement was not met as evidenced by facility failing to notify resident's physical therapist to address change in condition which posed a potential health & safety risk to resident 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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3