015600526-5-1-2020-15-AS-HHUL-BPBMMB-20200505094341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600526
Report Date: 05/01/2020
Date Signed: 05/01/2020 12:28:40 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
05/14/2019 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20190514091127

FACILITY NAME:	ELDERS INN ON WEBSTER		FACILITY NUMBER:	015600526
ADMINISTRATOR:	MARIE ANN LAGASCA		FACILITY TYPE:	740
ADDRESS:	1721 WEBSTER STREET		TELEPHONE:	(510) 521-9200
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94501
CAPACITY:	60	CENSUS: 40	DATE:	05/01/2020
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marie Lagasca, Administrator		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident’s injury.

INVESTIGATION FINDINGS:

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On 5/1/2020 at 11:30 AM, Licensing Program Analyst (LPA) L. Francisco conducted a complaint investigation for the above allegation over the phone due to shelter in place order directed by the Governor. LPA spoke to Administrator, Marie Lagasca.

During the course of the investigation, LPA K. Chow-Yau collected documents on 5/17/2019. On 5/1/2020, LPA Francisco interviewed 2 staff. Based on information obtained by complainant, early morning before 7:00 AM on 5/12/2019, resident (R1) was found on the bathroom floor for an unknown period of time while staff were asleep. However, based on incident report that occurred on 5/12/2019, resident was escorted to R1’s bedroom chair from the dining room and was found on the bathroom floor at 10:10 AM. Based on interview with S2, S2 assisted R1 on the toilet after breakfast and then assisted R1 to her chair.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2020

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-20190514091127

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: ELDERS INN ON WEBSTER	FACILITY NUMBER: 015600526
	VISIT DATE: 05/01/2020

NARRATIVE

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S2 went onto check on another resident next door and went back to R1’s room ten minutes later and found R1 on the floor by the bathroom.

LPA was unable to obtain additional information from R1 and no forthcoming information from complainant.

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 with Administrator over the phone and a copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2020

LIC9099 (FAS) - (06/04)

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