216803761-3-27-2024-21-AS-VBEI-D3YNAB-20240403101715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 03/27/2024
Date Signed: 03/27/2024 05:41:01 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/17/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20231017092122

FACILITY NAME:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	JOLLY CARUNGCONG		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	47	CENSUS:	DATE:	03/27/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Licensee, Mark Bello, and Administrator, Jolly Carungcong		TIME COMPLETED:	05:45 PM

ALLEGATION(S):

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Staff neglect/lack of supervision resulted in a resident sustaining a serious injury
Staff did not assist residents in a timely manner

INVESTIGATION FINDINGS:

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At approximately 1:30PM, Licensing Program Analyst (LPA) Felias delivered findings for a Complaint investigated by the Department regarding the above allegations and met with Licensee, Mark Bello, and Administrator, Jolly Carungcong. Complaint Findings were delivered in person at the Santa Rosa Regional Office. During the course of the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations.

The following allegations were investigated, “Staff neglect/lack of supervision resulted in a resident sustaining a serious injury, and Staff did not assist residents in a timely manner.” The Department reviewed facility records, facility logs, and conducted interviews with medical providers, residents, families, and facility staff.

Continued on LIC9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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 21-AS-20231017092122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
	VISIT DATE: 03/27/2024

NARRATIVE

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Continued from LIC9099
“Staff neglect/lack of supervision resulted in a resident sustaining a serious injury” - Resident 1 (R1) was admitted to the facility in June 2023. Facility reported that on 7/18/2023, R1 had decreased appetite and was having a hard time standing so R1’s Responsible Party was called, came to the facility and had R1 sent to the hospital where they were diagnosed with a left “displaced intertrochanteric hip fracture.” Per interviews with staff, R1 did not have an observed fall, however, 4 of 8 staff interviewed noted R1 complaining of pain, refusing care, and not feeling well on 7/17/2023. Interviews and multiple reports revealed that by 7/18/2023, R1 was complaining of pain and was not able to stand. Per interview and medical record review, R1’s leg was observed to be swollen on 7/18/2023.

Review of R1’s medical records dated 07/18/2023 noted that facility staff informed emergency personnel that R1’s leg was observed to be swollen since 07/17/2023. Per report, R1 had complained of hip pain on 07/16/2023 but was observed to still be able to bear their own weight. Review of facility’s 24-hour log dated 07/15/2023 and 07/16/2023, showed staff did not note any changes observed for R1. Facility reported that R1 had an unwitnessed fall on 10/08/2023, which staff responded to when they heard R1 calling for help. Per report, R1 was “visually assessed” by staff because R1 did not want to be touched. Two staff members assisted R1 into their wheelchair and then staff called the Administrator who called R1’s Responsible Party. R1’s Responsible Party arrived at facility and requested that R1 be sent to the hospital. R1 was sent to the hospital where they were diagnosed with a right “femoral neck fracture” per obtained medical records dated 10/08/2023. Review of Facility’s 24-hour log dated 10/08/2023, did not note any changes observed.

Review of R1’s Physician’s Report dated 06/08/2023, stated that R1 had a dementia diagnosis, had auditory, visual, and motor impairment, and needed assistance with their Activities of Daily Living (ADLs). Review of R1’s Needs and Services Plan, dated 06/24/2023, stated that R1 used a walker and needed help with ambulating and transferring. Review of R1’s Needs and Services Plan dated 06/24/2023, stated that R1 used a walker and required stand-by assistance with ambulating and transferring. Staff interviews conducted reported that they do not look at or have access to resident files and rely on facility management to inform them of resident care needs. Facility staff were unable to identify fall interventions to mitigate R1’s risk for falls. Interviews stated that interventions with R1’s Responsible Party were discussed but nothing was put in place. Review of facility records showed no indication that a care conference was held or that a reappraisal was completed. Review of Facility’s documentation indicated that in the event of a fall or post-fall assessment, staff are to report, access for serious injury and current condition, obtain fall history, assess environment, assess future fall risk, and analyze the fall and create a post fall action plan. Review of Facility’s Program Plan for “Policy and Protocol for Emergencies” stated the following: “Any and all medical emergencies that require assistance will be handled by first calling 911, notifying the resident’s physician, following with communication with the family or responsible party.

Continued on LIC9099C

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231017092122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 03/28/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a)...residents...shall have...personal rights:(4) To care, supervision, and services that meet...individual needs and...delivered by staff that are sufficient in numbers, qualifications, and competency...	1 2 3 4 5 6 7	Licensee to submit written plan outlining direct care staff training to be conducted. Plan shall include who is conducting the training, and cover these areas: Observation of a Resident, Fall Assessment Protocol, and 911 Emergency Services Protocol. Licensee to conduct In-Service Training for all direct
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: based on interviews conducted, records reviewed, and observations made, Licensee did not ensure that resident was assessed and emergency services sought. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	care staff. Plan to be submitted by POC due date of 03/28/2024. Training to be submitted no later than 04/10/2024 and include Date of Training, Training Topics, Job Role, Staff Names, and Signatures.
Type A 03/28/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by: based on interviews conducted, records	1 2 3 4 5 6 7	Licensee to submit written plan outlining direct care staff training to be conducted. Plan shall include who is conducting the training and cover this area: Responding to Resident Call Buttons Timely. Licensee to conduct In-Service Training for all direct care staff. Plan to be submitted by POC due date
	8 9 10 11 12 13 14	reviewed, and observations made, Licensee did not respond to residents in a timely manner. This poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	of 03/28/2024. Training to be submitted no later than 04/10/2024 and include Date of Training, Training Topics, Job Role, Staff Names, and Signatures.

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: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231017092122

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: GREENWOOD ASSISTED LIVING	FACILITY NUMBER: 216803761
	VISIT DATE: 03/27/2024

NARRATIVE

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Continued from LIC9099C
Some items that would be a medical emergency and 911 would be called are, but not limited to the following; expected heart attack, expected stroke, resident found unconscious, their breathing is compromised, seizures, uncontrolled bleeding, falls, etc.” This allegation is Substantiated.

“Staff did not assist residents in a timely manner” – Reporting Party stated that they have observed staff sleeping on the facility premises while on duty and have seen staff not responding to residents when they call for help. 3 of 4 staff interviews conducted stated that they had not observed or seen staff sleeping during facility hours. 1 of 4 staff interviews conducted stated they have seen staff members sleeping while on duty. 2 of 2 Resident interviews conducted stated that they have pressed their pendants multiple times before they received a response from care staff. Wait times were reported to be between 20 minutes to an hour. During a Department visit conducted on 11/28/2023, Community Care Licensing (CCL) staff observed that it took 16 minutes for care staff to respond to Resident 2’s (R2’s) pendant call and that they had pressed their pendant about 5 times. CCL staff were informed by the responding caregiver that they were unable to respond to the resident due to doing laundry and helping someone in the bathroom. CCL staff noted that while waiting for care staff to respond to R2’s pendant call, they observed one caregiver cleaning the dining room, one caregiver escorting a resident out of the dining room, and one caregiver walk past R2’s room. This allegation is Substantiated.

Based on the Department’s interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

A finding that the complaint allegation is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiencies, on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

**An immediate Civil Penalty in the total amount of $500 has been issued for a violation that resulted in the sickness or injury of a resident in care (See LIC-421IM) An additional civil penalty may be assessed based on Health and Safety Code 1569.49(e) or (f), or 1548(e) or (f), 1568.0822(e) or (f).**

Exit interview conducted. Plan of Corrections reviewed and developed with Licensee and Administrator. Copy of report, LIC9099-D, LIC-421IM, and Appeal Rights discussed and provided to Licensee and Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC9099 (FAS) - (06/04)

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