011400514-4-3-2024-15-AS-HHUL-D4CVK2-20240415162938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400514
Report Date: 04/03/2024
Date Signed: 04/03/2024 05:27:06 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
05/01/2023 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20230501130915

FACILITY NAME:	PIEDMONT GARDENS #1		FACILITY NUMBER:	011400514
ADMINISTRATOR:	WITTMAN, DANIEL		FACILITY TYPE:	741
ADDRESS:	110-41ST STREET		TELEPHONE:	(510) 654-7172
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94611
CAPACITY:	321	CENSUS: 63	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Zinniz Koch, Director of Wellness and Assisted Living		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff not administering medication as prescribed.

Staff mishandling residents medication.

Resident’s bathroom fan is in disrepair.

INVESTIGATION FINDINGS:

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On 4/3/2024 at 1:50pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Zinnia Koch, Director of Wellness and Assisted Living and explained the reason for the visit.

The Department interviewed the reporting party (RP), staff, obtained and reviewed records. The records reviewed included but not limited to Resident 1 (R1’s) medication administration record (MAR), clinical notes, residential appraisal, plan of care, physician's report, maintenance order log for R1's room.

Allegation: Staff not administering medication as prescribed.

RP stated during initial interview that staff was not administering all of R1's

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230501130915

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: PIEDMONT GARDENS #1	FACILITY NUMBER: 011400514
	VISIT DATE: 04/03/2024

NARRATIVE

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Continued from LIC9099.

medications. Notes from the RP, clinical notes, and the MAR from the facility indicated R1 refused medication on several occasions. Facility would sometimes contact R1's responsible party to persuade R1 to take medications. Clinical notes dated 3/4/2023 indicated comfort meds were received for R1. Further clinical notes dated 3/11/2023 indicated the facility had not received signed orders for medication; however, on 3/15/2023, the facility received the updated medication list, changes were noted, and profiled was updated. R1 no longer resides at facility. Based on the investigation the above allegations are unsubstantiated.

Allegation: Resident’s bathroom fan is in disrepair.

During interview RP stated there were multiple bathroom fans in disrepair for two (2) months. LPA did not observe a work order for a bathroom fan. LPA toured apartment where R1 resided and two (2) additional apartments and did not observe fans in any of the bathrooms.

Allegation: Staff mishandling residents medication.

RP stated during interview that R1 had found a pill on the floor. During interviews and records reviews LPA was not told or did not observe where medication was found by staff or any other person. LPA obtained medication management training records for the licensed nurses, CNAs and Med Techs dated 3/10/2023 to 3/14/2023.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

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