015600413-2-21-2024-15-AS-YFLS-D64UWL-20240610155654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600413
Report Date: 02/21/2024
Date Signed: 02/21/2024 01:32:21 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
02/06/2023 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20230206152229

FACILITY NAME:	BELLAKEN GARDEN		FACILITY NUMBER:	015600413
ADMINISTRATOR:	BELINDA LEUNG		FACILITY TYPE:	740
ADDRESS:	2780 26TH AVENUE		TELEPHONE:	(510) 536-1838
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94601
CAPACITY:	58	CENSUS: 51	DATE:	02/21/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Jeffrey Tong, Administrator		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained an ulcer in care at the facility due to staff neglect.

INVESTIGATION FINDINGS:

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On 2/21/24 at 10:30 a.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to deliver findings for the above allegation. LPA met with Jeffrey Tong, Administrator and explained the purpose of the visit
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During the course of investigation, the Department interviewed: W1, W2, 5 facility staff (S1, S2, S3, S4 and S5) and 3 facility residents (R1, R2 and R3). The Department also reviewed R1’s medical records.

On 9/22/2022 R1 was admitted to Bellaken Garden and had a stage one pressure injury on her back. Facility staff informed the family and made a note in R1’s admission documents that R1 had a stage one pressure injury to her back. R1 was admitted to Kaiser Hospital on 11/15/22. A review of the medical records from Kaiser Permanente (11/15/22 – 11/19/22) showed a total of three pressure injuries that never progressed past stage two.

***report continues on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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-20230206152229

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: BELLAKEN GARDEN	FACILITY NUMBER: 015600413
	VISIT DATE: 02/21/2024

NARRATIVE

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***report continues from LIC9099***

Review of home health records (11/19/22) showed that when R1 was released from Kaiser Permanente on 11/19/2022 before returning to the assisted living side of Bellaken Garden, the home health nurse noted that R1 needed skilled nursing care.

While in the assisted living side of Bellaken Garden R1's pressure injuries progressed from stage 3 to unstageable. R1 stayed in assisted living of Bellaken Garden for two weeks before she was transferred to the skilled nursing side of Bellaken Garden due to waiting on doctor approval. R1 continued to receive home health nurse services until her transfer to skilled nursing.

The Department has investigated the complaint alleging a resident sustained an ulcer in care at the facility due to staff neglect. We have found that the complaint was unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC9099 (FAS) - (06/04)

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