216803761-4-11-2023-21-AS-KMOA-CR3TB3-20230420143427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216803761
Report Date: 04/11/2023
Date Signed: 04/11/2023 01:30:26 PM

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
01/10/2023 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20230110133538

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: 20	DATE:	04/11/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Executive Director, Neysa Hinton, and Director of Care/Administrator, Jolly Carungcong		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility is not allowing visitation
Medications not dispensed as prescribed
Facility failed to safeguard residents personal belongings
Call bell not responded to timely

INVESTIGATION FINDINGS:

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At approximately 12:35PM, Licensing Program Analyst (LPA) Felias arrived unannounced to deliver findings for a Complaint Investigation regarding the above allegations and met with Executive Director, Neysa Hinton, and Director of Care/Administrator, Jolly Carungcong.

During the course of the Investigation, Licensing Program Analyst (LPA) Felias reviewed and requested documents, made observations at the facility, and conducted interviews.
There is an allegation that Facility is not allowing visitation. Report provided to LPA on 1/10/2023 stated that the facility prevented or banned individuals from visiting Resident 1 (R1). Staff Interviews conducted stated that the facility does not restrict individuals from visiting as it is a Resident’s Right to visit with whomever they want. Record Review indicated that the facility has allowed visitation for R1, and that visitors can meet with them in the facility’s conference room located in the lobby. Based on interviews conducted and review of documents, the LPA is unable to determine if the facility is not allowing visitation.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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 3

Control Number 21-AS-20230110133538

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: 04/11/2023

NARRATIVE

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Continued from LIC9099

Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that Medications are not being dispensed as prescribed. Records reviewed for R1 showed that R1 is on Hospice and has their medications prescribed and ordered through their Hospice Agency. Review of R1’s Medication Administration Record (MAR) showed that the facility has been administering R1’s medication as prescribed, and that there have been no medication changes made since R1 moved into the facility. Based on records reviewed, LPA is unable to determine if Medications were not being dispensed as prescribed. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that the Facility failed to safeguard residents personal belongings. Report provided to LPA on 1/10/2023 stated that the facility did not safeguard R1’s dentures and that they were misplaced. Interviews conducted stated that the facility failed to keep R1’s dentures safe resulting in the dentures getting thrown out but that R1 received replacement dentures two weeks after the incident. Record Review showed that R1’s personal property inventory did not have dentures listed. Review of Facility’s Loss and Theft Policy showed that R1’s responsible party was informed of the policy on 11/22/2022. Based on records reviewed and interviews conducted, the LPA is unable to determine if the facility failed to safeguard residents personal belongings. Therefore, the allegation is UNSUBSTANTIATED.

There is an allegation that Call bells are not responded to timely. Staff interviews conducted stated that the facility does not have a call bell light log but that they check on residents every two hours. Interviews conducted stated that resident bathroom and bedroom call lights are manually reset. Each resident also has a necklace call light which is programmed to have an identifying ring tone. During visit conducted on 03/17/2023, LPA observed the Director of Care, Jolly Caruncong, use a walkie talkie to radio all care staff in the facility when a resident would call. LPA also observed care staff walking up and down the halls checking on residents, providing care to residents, and assisting residents to go to lunch. Interviews conducted also stated that facility will document two hour checks if ordered by a resident’s Physician or by the request of the Responsible Party. Based on interviews conducted and observations made, the LPA is unable to determine if call bells were not responded to timely. Therefore the allegation is UNSUBSTANTIATED.

Continued on LIC9099C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20230110133538

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: 04/11/2023

NARRATIVE

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Continued from LIC9099C

A finding that the Complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC 811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC9099 (FAS) - (06/04)

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