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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201040
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:47:43 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
08/17/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230817132316
FACILITY NAME:CATHEDRAL CARE HOMEFACILITY NUMBER:
079201040
ADMINISTRATOR:DATUIN, MARIVICFACILITY TYPE:
740
ADDRESS:2707 CATHEDRAL CIRCLETELEPHONE:
(925) 222-8492
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marivic Datuin, Administrator
Donna Vargas, Staff		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff not providing accurate dosage of medications to resident
INVESTIGATION FINDINGS:
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On 10/20/23 at 12PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit, met with staff (S3) and spoke to administrator (ADM) on the phone who authorized S3 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (ADM,S3) and delivered investigation findings.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, admission agreement, physicians report, needs & services plans, hospital discharge summary report, hospice care plan assessments, physicians’ orders, narrative charting, medication worksheets, death report. 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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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-20230817132316
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: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040
VISIT DATE: 10/20/2023
NARRATIVE
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Allegation: Staff not providing accurate dosage of medications to resident
Investigation Finding: Substantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. Review of R1’s admission agreement showed R1 was first admitted at the facility on 08/21/2021. Due to a change in condition, staff sent R1 to the hospital on 08/06/23, was admitted for treatment of physical deconditioning and discharged back to the facility on 08/12/23 with hospice care.

Administrator (ADM) and authorized representative (POA) agreed to implement R1’s written hospice care plan (comfort measures only) dated 08/12/23 prior to the initiation of R1’s hospice care. ADM implemented R1's hospice care plan starting 08/12/23 until 08/15/23. Review of hospice care’s physician’s order dated 08/15/23 show R1’s comfort drugs dosages were increased by the hospice care physician to manage R1’s pain and anxiety. LPA interviewed ADM who stated that she refused to implement R1’s increased comfort drug dosages on 08/16/23 because she is a hospice nurse and did not believe in the hospice physician’s assessment. POA and family had to implement hospice doctor’s orders for increased comfort drug dosages until R1 passed on 08/19/23. Based on the department’s observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) that staff was not providing accurate dosage of medications to resident was found to be substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. 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 copy of report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230817132316
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: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
87633(a)(4)
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A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident’s hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident’s or prospective resident’s Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).
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By POC due date, administrator agreed to complete and submit to CCL proof of in-service staff re-training on hospice care of terminally ill residents in compliance with Title 22 Section 87633(a)(4).
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This requirement was not met as evidenced by staff not providing accurate dosage of medications to resident which posed a potential health & safety risk to resident 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: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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
08/17/2023 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20230817132316

FACILITY NAME:CATHEDRAL CARE HOMEFACILITY NUMBER:
079201040
ADMINISTRATOR:DATUIN, MARIVICFACILITY TYPE:
740
ADDRESS:2707 CATHEDRAL CIRCLETELEPHONE:
(925) 222-8492
CITY:BRENTWOODSTATE: CAZIP CODE:
94513
CAPACITY:6CENSUS: 5DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Marivic Datuin, Administrator
Donna Vargas, Staff		TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff not rotating and repositioning resident resulting in pressure sore(s)
Staff left resident in soiled diapers resulting in resident sustaining redness in private area
INVESTIGATION FINDINGS:
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On 10/20/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit, met with staff (S3) and spoke to administrator (ADM) on the phone who authorized S3 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (ADM,S3) and delivered investigation findings.

Allegation: staff not rotating and repositioning resident resulting in pressure sore(s)
Investigation Finding: Unsubstantiated
During investigation, the department conducted interviews of facility staff & responsible parties and reviewed resident (R1) documents. LPA interviewed staff (ADM, S3) who stated that they implemented R1’s hospice care plan as instructed. Continued on next page, LIC 9099-C pg2.
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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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-20230817132316
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: CATHEDRAL CARE HOME
FACILITY NUMBER: 079201040
VISIT DATE: 10/20/2023
NARRATIVE
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S3 stated S1 was the main caregiver of R1 and was no longer employed at the facility. LPA was unable to reach S1 by phone. Review of hospice records dated 8/14/23 showed hospice nurse noted R1 had blancheable pink area to bilateral heels on feet and instructed staff to float heels to avoid potential risk of the development of pressure sore(s). Hospice nurse did not observe or report presence of any pressure injuries on R1 during visits.

Review of hospice notes dated 08/12/23 thru 8/15/23 showed hospice nurses assisted staff in changing and repositioning R1 and instructed staff on the proper technique for turning and repositioning R1 every 2 hours with heels floated to avoid the risk of pressure injuries. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff was not rotating and repositioning resident resulting in pressure sore(s) and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff was not rotating and repositioning resident resulting in pressure sore(s) is unsubstantiated.

Allegation: Staff left resident in soiled diapers resulting in resident sustaining redness in private area
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (ADM, S3) who denied leaving R1 in soiled diapers for extended periods of time resulting in redness in private area. Staff stated they followed R1’s hospice care plan and changed R1’s diapers frequently. Review of R1’s hospice care records dated 08/12/23 thru 08/19/23 did not show resident sustained redness in private area while in care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff left resident in soiled diapers resulting in resident sustaining redness in private area and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Therefore, the allegation that staff left resident in soiled diapers resulting in resident sustaining redness in private area is unsubstantiated.

Exit interview conducted 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: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5