216803761-10-29-2020-21-AS-CMAZ-BUWSZK-20201031141917

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 10/27/2020
Date Signed: 10/29/2020 08:14:16 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20200501152400

FACILITY NAME:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	GRENAS, ANGELA		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	47	CENSUS:	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator Lisa DiBartolo		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Residents sustained serious injuries from falls requiring hospitalization
Staff failed to seek residents timely medical attention after falling
Staff failed to report residents' falls

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert contacted Administrator Lisa DiBartolo this date for the purpose of delivering findings on the above captioned complaint allegations. The visit was conducted via tele - visit due to the COVID - 19 precautions. It is alleged that R1 and R2 had unwitnessed falls causing injuries and that staff did not report the incidents or seek timely medical care for R1 and R2. This Department has investigated these allegations by obtaining records and conducting interviews. The following determinations have been made: R1 and R2 had cognitive deficiencies; were Hospice patients; and passed in August and November 2019; Records show that facility reported injuries/pain incidents on five occasions, one incident for an unwitnessed fall; there are differing opinions as to whether timely medical attention was provided following the referenced incidents; with the exception of the one fall which was reported, no evidence was found that would suggest the other injuries were caused by falls; request by this Department for a medical opinion from the treating physician regarding the cause of the injuries not been answered. Although the allegations may be valid, based upon documents and statements, there is not a preponderance of evidence to prove that they are, or are not, true. Therefore, the allegations are UNSUBSTANTIATED.

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: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/01/2020 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20200501152400

FACILITY NAME:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	GRENAS, ANGELA		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	47	CENSUS:	DATE:	10/27/2020
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Administrator Lisa DiBartolo		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Residents' alarm equipment did not function properly

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert contacted Administrator Lisa DiBartolo this date for the purpose of delivering findings on the above captioned complaint allegations. The visit was conducted via tele - visit due to the COVID - 19 precautions. It is alleged that the alarm equipment, call buttons and fall mats, which were installed in the bedroom of R1 and R2 did not function properly and that staff did not always respond when summoned to the bedroom. The allegation is denied. This department has investigated the allegation by reviewing and obtaining documents and by conducting interviews with staff and witnesses. The following determinations have been made: In addition to the Complainant, three witnesses who have visited the facility report incidents when they observed the alarm equipment not working properly or in need of batteries. Based upon the interviews conducted, the preponderance of evidence standard has been met. Therefore, the above captioned 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: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

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 3

Control Number 21-AS-20200501152400

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/27/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/02/2020 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of the residents, employees and visitors. **Based upon interviews, this requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Administration to provide a written plan that addresses what protocols will be put in place to assure that the alarm systems function properly. Plan to be submitted to CCL by POC date in order to clear the deficiency.
	8 9 10 11 12 13 14	Witnesses that visited the facility report that residents' alarm systems have not functioned properly. This posed an immediate risk to the safety of residents in care.	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: 10/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020

LIC9099 (FAS) - (06/04)

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