079201196-3-11-2025-15-AS-HHUL-DHANKL-20250603103207

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201196
Report Date: 03/11/2025
Date Signed: 03/11/2025 12:45:01 PM

Unsubstantiated

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
06/15/2023 and conducted by Evaluator Alicia Delmundo

COMPLAINT CONTROL NUMBER: 15-AS-20230615163239

FACILITY NAME:	COGIR OF BRENTWOOD		FACILITY NUMBER:	079201196
ADMINISTRATOR:	HARRISON, DAMIKA		FACILITY TYPE:	740
ADDRESS:	150 CORTONA WAY		TELEPHONE:	(925) 240-0733
CITY:	BRENTWOOD	STATE: CA	ZIP CODE:	94513
CAPACITY:	150	CENSUS: 127	DATE:	03/11/2025
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Cayia Henry/Executive Director		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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-Resident (R1) developed stage 3 pressure injury while in care.

-Staff do not assist resident (R1) with incontinence needs.

INVESTIGATION FINDINGS:

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On this day, March 11, 2025, at 12:00 noon, Licensing Program Analyst (LPA) Delmundo conducted an unannounced visit to deliver findings for the above allegations. LPA met with Executive Director (ED) Cayia Henry and informed the reason for visit.

During the course of investigation, the Department obtained copies of resident roster and staff schedule. Copies of the following resident records were also obtained: medical records, Resident Information and Contact Sheet; Resident Face Sheet; Admission Agreement; Pre-admission Appraisal; Service Plan; LIC602A Physician's Report; Unusual Incident Reports; facility notes; Home Health Visit notes. Staff (S1, S2, S3, S4, S5, S6, S7 and previous Executive Director) were interviewed on 9/28/23, 10/04/23, 10/12/23. R1’s family member (FM1) was also interviewed on 9/29/23, home health nurse (HHN) on 10/31/23, and residents (R2, R3, R4) on 10/04/23.

........continued on 9099C (page 2)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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-20230615163239

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: COGIR OF BRENTWOOD	FACILITY NUMBER: 079201196
	VISIT DATE: 03/11/2025

NARRATIVE

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Allegation: Resident (R1) developed stage 3 pressure injury while in care.
Medical records revealed that R1 was admitted to the hospital on 3/17/23 due to acute cholecystitis. R1 informed the nurse about having the pressure injury prior to being admitted to the hospital. R1 was developing a coccyx deep tissue pressure injury and was provided home health services when R1 was discharged back to the facility on 3/17/2023. The Department observed that the medical records do not indicate that R1 presented at hospital on 3/17/23 with a pressure wound. The medical records indicate that a developing wound was noted after hospital admission; that R1 was discharged back to the facility with Home Health orders; and that Home Health records noted progressive healing, and was healed at the time of Home Health discharge in June 2023.

Interviews with S1, care staff and med-techs (S2, S3, S4, S5, S6 and S7) revealed consistent statements of R1 refusing to be transferred and requiring staff assistance to be transferred from R1’s recliner, bed, and toilet. Staff denied remembering that R1 had a stage 3 pressure injury. S1 denied knowing the stage of R1’s pressure injury despite HHN confirming that S1 saw R1’s pressure injury and was aware that R1’s wound was a stage 3. HHN visited R1 frequently and treated the pressure injury. HHN did not believe the facility staff contributed to R1’s pressure injury developing into a stage 3. R1’s pressure injury responded well to the treatment by HHN which healed by June 2023. HHN did not have any concerns regarding facility staff and care of R1’s pressure injury. Therefore, the allegation is unsubstantiated.

Allegation: Staff do not assist resident (R1) with incontinence needs.
Reporting party (RP) stated the night staff tell R1 to wet her bed instead of getting her up to the restroom. RP further stated that the morning staff stated they saw R1 had been sitting in her feces, and the night shift did not change her. Review of records showed FM1 brought up these issues to the previous ED. FM1 sent email to previous ED stating R1 was not refusing to go to the bathroom with the bedside commode and wanted the staff to ‘ignore’ R1 and get R1 up to toilet.

.....continued on 9099C (page 3)

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20230615163239

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: COGIR OF BRENTWOOD	FACILITY NUMBER: 079201196
	VISIT DATE: 03/11/2025

NARRATIVE

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All staff stated R1 was a 2 person assist in transferring and would at times refuse care. S6 stated that R1 was a two person assist and needed assistance with getting from R1’s recliner to the bathroom. S6 also stated that R1 would page the caregivers for help every 2 to 3 hours, and when R1 did not page, S6 would still check to make sure R1 was okay.

HHN stated R1 was clean every time HHN went to the facility. HHN did not have any concerns regarding the facility and indicated the staff provided adequate care to R1.

R2 does not know R1. R2 expressed satisfaction with the care R2 was receiving at the facility. R3 denied knowing R1. R3 stated she’s not able to walk and has several disabilities that do not allow her to leave her bed and she gets the attention she needed from the care staff. R3 also stated she felt there weren’t any incidents where the care staff did not meet her needs. R4 stated knowing R1 but does not know about the care R1 was receiving from the staff. R4 stated she’s happy with the caregivers. The Department was not able to obtain information from R1. Therefore, the allegation is unsubstantiated.

Based on records review, interviews, and the Department unable to obtain information from R1, the 2 allegations are closed as unsubstantiated. A finding that a complaint is unsubstantiated means that although the allegations may have happened or are valid there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiency cited.

Exit interview conducted and copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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