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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 12/19/2023
Date Signed: 03/27/2024 05:34:45 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
04/17/2023 and conducted by Evaluator Caitlynn Felias
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20230417124321
FACILITY NAME:GREENWOOD ASSISTED LIVINGFACILITY NUMBER:
216803761
ADMINISTRATOR:JOLLY CARUNGCONGFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:47CENSUS: 21DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Director of Care/Administrator, Jolly CarungcongTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff left resident soiled for an extended period of time
Staff did not provide clean linen to resident in care
INVESTIGATION FINDINGS:
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At approximately 1:20PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint investigated by the Department regarding the above allegations and met with Administrator, Jolly Carungcong. During the course of the Investigation, the Department requested and reviewed documents, conducted interviews, and made observations.

The following allegations were investigated, “staff left resident soiled for an extended period of time, and staff did not provide clean linen to resident in care”. During the investigation the Department reviewed facility records, requested facility logs, conducted interviews with Hospice providers, residents, families, and facility staff. Resident 1 (R1) was admitted to Greenwood Assisted Living in September of 2021, and placed on hospice care around that same time. R1 became bed bound around November of 2022.

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 5
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
04/17/2023 and conducted by Evaluator Caitlynn Felias
COMPLAINT CONTROL NUMBER: 21-AS-20230417124321

FACILITY NAME:GREENWOOD ASSISTED LIVINGFACILITY NUMBER:
216803761
ADMINISTRATOR:JOLLY CARUNGCONGFACILITY TYPE:
740
ADDRESS:233 WEST END AVETELEPHONE:
(415) 258-1560
CITY:SAN RAFAELSTATE: CAZIP CODE:
94901
CAPACITY:47CENSUS: 21DATE:
12/19/2023
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Director of Care/Administrator, Jolly CarungcongTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident in a timely manner
Staff did not ensure resident was being fed
INVESTIGATION FINDINGS:
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Additionally, the Department investigated the above allegations of “staff did not ensure resident was being fed and staff did not seek medical attention to resident in a timely manner”. The Department reviewed facility records, requested facility logs, and conducted interviews with Hospice providers, residents, families, and facility staff. Interviews conducted stated that R1 had difficulty eating, had poor calorie intake, declined most of their meals, and only ate about 20-25% of meals. Review of Hospice Records dated 08/22/2022 stated that R1 has a poor appetite with a minimal intake of 30% of their daily meals. Review of documents showed that facility kept a log to monitor R1’s care and food intake however facility was unable to locate completed log documents. Interview conducted with Reporting Party stated that the Facility notified them of a lip injury that occurred when R1 was being fed by staff. Family stated that R1 should have been sent to the
Emergency Room. The Hospice nurse assessed R1 and determined that R1 did not need stitches.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
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 5
Control Number 21-AS-20230417124321
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: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761
VISIT DATE: 12/19/2023
NARRATIVE
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Continued from LIC9099

Interviews conducted with facility staff stated that first aid was applied after R1 sustained the cut lip. Based on information obtained these allegations are Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegations may have happened there is not a preponderance of evidence to prove that the allegation occurred.

Exit interview conducted. Copy of report discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20230417124321
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: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761
VISIT DATE: 12/19/2023
NARRATIVE
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Continued from LIC9099
During our investigation we learned four (4) of the nine (9) staff interviewed, and two (2) of the hospice staff interviewed (an RN and Home Health Aide), observed R1 to be left in soaked or soiled briefs, and found R1 to be lying on their back numerous times in a week. Please note hospice staff visited R1 at the facility twice or more a week. R1’s responsible parties were interviewed, and it was noted they also observed R1 in soiled briefs, and not repositioned. R1's care plan stated they were to be changed and repositioned every 2 hours. The facility indicated they had a log of dates/times with staff initials as to when R1 was changed and repositioned however they were not able to provide copies of these logs. It was reported by a visitor of R1 that they observed R1’s linens to be soiled and reported it to facility staff. The visitor visited the next day after reporting the soiled linens to staff and observed the soiled linens to have not been changed. Visitor stated that they were told by facility staff that changing R1’s linens was the Hospice agency’s responsibility. Interviews conducted with Hospice providers stated that there were multiple times that R1’s linens were found to be soiled. Review of R1’s Hospice Care Plan dated 07/19/2022, stated that Hospice is responsible for changing linens once per week. Review of R1’s Admissions Agreement dated 09/25/2021 stated that “fresh linen is provided weekly or as necessary.” Facility’s Program Plan states the following: “basic services for all residents in the facility include cleaning residents’ beds and linens weekly, or more often as needed.” Investigation findings revealed the facility did not ensure they followed R1’s Care Plan.

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.

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

Exit interview conducted. Plan of Corrections reviewed and developed with Administrator. Copy of report, LIC9099-D, and Appeal Rights discussed and provided to Administrator. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20230417124321
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: GREENWOOD ASSISTED LIVING
FACILITY NUMBER: 216803761
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
12/20/2023
Section Cited
CCR
87633(d)
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*Amended* 87633 Hospice Care of Terminally Ill Residents:(d)Licensee shall ensure... the hospice care plan is current... matches the services actually being provided, & that client’s care needs are being met at all times. Requirement was not met as evidenced by: based on interviews, records
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Licensee to submit a plan that addresses how Facility will comply with the requirements of 87633(d) going forward by POC due date of 12/20/2023. Licensee to conduct In-Service Training with all direct care staff to discuss repositioning, incontinence care, linen services, and updating service plans policies.
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reviewed, & observations, staff failed to meet R1’s bladder & bowel needs based upon statements obtained during investigation which indicated R1 was found frequently to be in urine or bowel soaked briefs & soiled linens.This poses an immediate health & safety risk.
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Training to be submitted by POC due date of 12/29/2023 and include Date of Training, Training Topics, Job Role, Staff Names, and Signatures.

CCR
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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 BertozziTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5