216803747-7-12-2022-21-AS-KMOA-CGBLU7-20220714090326

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803747
Report Date: 07/11/2022
Date Signed: 07/12/2022 11:06:21 AM

Unsubstantiated

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
06/15/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220615145525

FACILITY NAME:	THREE HOME VILLAGE 3		FACILITY NUMBER:	216803747
ADMINISTRATOR:	FLATT, ERIK		FACILITY TYPE:	740
ADDRESS:	679 ROSAL WAY		TELEPHONE:	(415) 492-1220
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	07/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Adam Waskow		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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9

Staff left resident in care in soiled undergarments for extended periods of time
Staff failed to inform physician of resident's change in condition
Staff failed to inform responsible parties of change in condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Adam Waskow and discussed the findings. During the course of this investigation, the Department interviewed staff and other witnesses, reviewed photographs, obtained documents, and made site visits to the facility. The following determinations are made: Complainant alleges facility staff did not report R1's change in condition and did not provide adequate hygiene care for R1; Personal physician for R1 states physician was notified of changes and that care of residents at the facility is excellent; Hospice nurse states facility staff have provided good care for R1; This Department has found no evidence of that staff did not make necessary reports or left R1 in soiled condition; No care notes for the month of April 2022 have been provided by facility for review and staff claim an extensive search for the notes has been made. Administrator states allegations are unfounded and states an appeal will be made. Although the allegations may be valid, or true, based upon the statements made and lack of critical documents, there is not a preponderance of evidence to prove the allegations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED. Report left at facilty. No citations issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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 4

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
06/15/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220615145525

FACILITY NAME:	THREE HOME VILLAGE 3		FACILITY NUMBER:	216803747
ADMINISTRATOR:	FLATT, ERIK		FACILITY TYPE:	740
ADDRESS:	679 ROSAL WAY		TELEPHONE:	(415) 492-1220
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 6	DATE:	07/11/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Adam Waskow		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to seek timely medical care for resident in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on the above captioned complaint allegations. LPA met with Adam Waskow and discussed the findings. During the course of this investigation, the Department interviewed staff and other witnesses, reviewed photographs, obtained documents, and made site visits to the facility. The following determinations are made: R1's skin condition worsened on or about April 11, 2022; On 4/12 triage was held with caregiver(S1), R1's Responsible Person and RN. RN advised S1 that R1 should be seen "within the next few hours;" R1 was not seen until 4/13 when R1 was taken to the ER by R1's RP; Administrator states notifications required by regulations were made and that RP customarily provided transportation for R1 to medical appointments; Administrator states that the allegation is unfounded. Based upon the photographs and records reviewed, as well as statements made by staff and witnesses, the preponderance of evidence standard has been met. Therefore, the allegation is SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 21-AS-20220615145525

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: THREE HOME VILLAGE 3	FACILITY NUMBER: 216803747
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/14/2022 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: Based on statements, photographs, documents, staff did not arrange, or assist in arranging, timely medical care for	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, with proof of training to follow within 2 weeks in order to clear the deficiency.
	8 9 10 11 12 13 14	R1 when advised to do so by Licensed Medical Professional. 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: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4