216803761-10-13-2021-21-AS-HDBI-C7ZVEY-20211021162308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 10/13/2021
Date Signed: 10/13/2021 12:18:52 PM

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
08/16/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210816102742

FACILITY NAME:	GREENWOOD ASSISTED LIVING		FACILITY NUMBER:	216803761
ADMINISTRATOR:	LISADIBARTOLO&ANGELAGRENAS		FACILITY TYPE:	740
ADDRESS:	233 WEST END AVE		TELEPHONE:	(415) 258-1560
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94901
CAPACITY:	47	CENSUS: 15	DATE:	10/13/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Licensee, Mark Bello		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility abandoned resident at the Hospital

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced at Greenwood Assisted Living for the purpose of delivering complaint findings. LPA was greeted at the door by Licensee, Mark Bello. LPA was granted access into the facility.

During the course of the investigation, LPA interviewed Licensee, witnesses and various outside parties, reviewed various documents including resident, staff and facility records.

Complaint alleges that Facility abandoned resident at the Hospital. Based on LPA observation of resident records, facility records and confidential interviews that were conducted, LPA learned that Resident #1 (R1) had a fall on August 12, 2021 and was admitted to the Hospital. On August 14, 2021, Licensee was notified by hospital staff that R1 was ready to be discharged back to the facility. (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

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-20210816102742

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
	VISIT DATE: 10/13/2021

NARRATIVE

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Licensee advised Hospital that the current Hospice Nurse assigned to R1 would not be allowed to come into the facility because Licensee felt that the Hospice Nurse was not wearing full proper Personal Protective Equipment (PPE) and was exposed to COVID-19. The investigation determined that the Hospice Nurse is a Licensed Skilled Professional and is trained on proper Donning and Doffing procedures. LPA was unable to obtain evidence that the Hospice Nurse was not properly donning or that they had a direct exposure to Covid-19 which would prevent them from entering the facility. Investigation confirmed that there was no indication that the nurse who was well trained on proper PPE use including donning and doffing or confirmed concern over the hospice nurse posing any COVID exposure risk. Licensee requested a different Hospice Nurse from the Hospital, which left R1 at the hospital for an additional day awaiting to be discharged back to the facility until licensee agreed to take R1 at 06:00 AM the next morning.

Based on interviews, records reviewed, LPA observations that were conducted, the allegation of Facility Abandoned resident is Substantiated. The preponderance of evidence standard has been met and the above allegation is SUBSTANTIATED. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Exit interview conducted and appeal rights were given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210816102742

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: 10/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/14/2021 Section Cited CCR 87455(a)(b)(2)	1 2 3 4 5 6 7	87455(a)(b)(2)-Acceptance and Retention Limitations: (a) Acceptance or retention of residents by a facility shall be in accordance with the criteria specified in this article 8 and Section 87605, Health and Safety Protection, and the following. (b) The following persons may be accepted or retained in the facility: (2) Persons receiving medical care and treatment outside the facility or who are receiving needed medical care from a visiting nurse. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Licensee will ensure that residents ready for discharge from the hospital that meet Title 22 regulations Acceptance and Retention Limitations are admitted back to the facility in a timely manner. Licensee will submit a plan of future compliance and a plan for in-service staff
	8 9 10 11 12 13 14	Based on interviews and LPA observation of records, it was determined Facility refused to admit 1 of 1 resident (R1) back from the Hospital 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	training regarding Acceptance and Retention Limitations as well as current COVID-19 PINS/Guidelines to Rohnert Park CCL by POC date of 10/14/2021. Proof of staff training along with a sign-in sheet shall be furnished to the Rohnert Park CCL by 10/25/2021.
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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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2021

LIC9099 (FAS) - (06/04)

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