216803239-12-22-2022-21-AS-BMOS-CMQQM3-20230103111653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803239
Report Date: 12/22/2022
Date Signed: 12/22/2022 01:40:10 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/28/2022 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20221028104235

FACILITY NAME:	BELLO GARDENS ASSISTED LIVING		FACILITY NUMBER:	216803239
ADMINISTRATOR:	VIERRA, CHARLEEN		FACILITY TYPE:	740
ADDRESS:	46 MARIPOSA AVENUE		TELEPHONE:	(415) 453-3494
CITY:	SAN ANSELMO	STATE: CA	ZIP CODE:	94960
CAPACITY:	25	CENSUS: 19	DATE:	12/22/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Executive Director, Neysa Hinton		TIME COMPLETED:	01:50 PM

ALLEGATION(S):

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Facility did not provide timely medical attention to resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegation. LPA met with Executive Director Neysa Hinton as Administrator Charleen Vierra out.
Complaint alleges facility did not provide timely medical attention to resident in care. On 10/20/2022 the department received an unusual incident report regarding an unwitnessed fall for resident (R1) resulting in an injury needing medical attention. On 10/28/2022 Community Care Licensing (CCL) received a report of suspected abuse regarding injury of R1 on 10/15/2022. Based on LPA Hansen’s investigation, Marin Central Police Authority report, officers arrived at facility at approximately 3:24PM to assist a resident needing medical attention. Hospice nurse informed officer that staff (S1) contacted the Hospice Agency at 2:35pm and hospice nurse arrived at 3:02pm responding to R1 sustaining a large laceration to the right front side of head. Interviews conducted by officers at the scene found that staff (S1) contacted Administrator who informed S1 not to call 911 and just to call the hospice nurse.
Continue on LIC9099-D

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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 21-AS-20221028104235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLO GARDENS ASSISTED LIVING	FACILITY NUMBER: 216803239
	VISIT DATE: 12/22/2022

NARRATIVE

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It is indicated that R1 had sustained an injury from an unwitnessed fall at approximately 1:50pm and appropriate emergency medical attention was not contacted until 3:24pm. Based on LPAs interviews and record review R1 had a large amount of blood soaking through applied several gauze pads and nurse and Officer informed either verbally or in report that R1s skull was visible due to injury.
In addition, Administrator’s statements to Marin Central Police Authority and LPA Hansen confirm Administrator did not choose to seek emergency medical attention from R1’s initial injury resulting in an approximate two hour time gap between initial injury and arrival of Emergency Medical System (EMS). R1 was transported to the ER and received medical attention and five stiches to laceration.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be Substantiated. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given

Executive Director or Administrator will be sending R1's Hospital ER Discharge documents from hospital visit of 10/15/2022 by EOB 12/30/2022.

The licensee was informed that civil penalties are under review by the Department per Health and Safety Code 1569.49 (f).

The Regional Office will be conducting an informal meeting to discuss concerns identified by the Department.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221028104235

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: BELLO GARDENS ASSISTED LIVING	FACILITY NUMBER: 216803239
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/22/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/23/2022 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465(a)(1) Incidental Medical and Dental Care. The Licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of the residents. ***This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administration shall provide refresher training to all care staff regarding the requirements of 87465 and submit, by POC date, schedule and topic outline to CCL(1st due date12/23/22), with proof of training to follow within 2 weeks in order to clear the deficiency (final due date (1/4/2023).
	8 9 10 11 12 13 14	Based on record review, statements, documents, and interviews, at Administrators request staff did not seek emergency medical attention immediately, R1 remained at facility 2 hours with a head wound needing 5 stitches. This posed an immediate risk to the health of R1.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC9099 (FAS) - (06/04)

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