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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 247203432
Report Date: 05/03/2023
Date Signed: 05/08/2023 11:48:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230111113614
FACILITY NAME:GUARDIAN ANGEL HOME CARE IIFACILITY NUMBER:
247203432
ADMINISTRATOR:SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:6CENSUS: 4DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility staff, Socorro RamirezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Resident sustained fracture while in care
Staff did not seek medical attention to resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with Facility staff, Socorro Ramirez and explained the purpose of today's visit.
Regarding the allegation Resident sustained fracture while in care. On 11/01/2022, Resident 1 began receiving hospice services, and was seen twice a week. During the visits both Home Health Aides (HHA) and the Registered Nurse advised and instructed the facility care staff that Resident 1 was a fall risk and not to leave them unattended. On 11/29/2022, at approximately 0800 hours, Staff 1 assisted Resident 1 to the restroom to shower. Resident 1 sustained a fall in the restroom and HHA arrived at the facility for a scheduled visit. Staff 1 told her that Resident 1 had sustained a fall and she did not know how Resident 1 fell. Social Services interviewed Staff 1 and she denied leaving Resident 1 unattended. Based on Resident 1’s body position, it was determined that Staff 1 left Resident 1 unattended on the commode, and when she returned Resident 1 was on the floor. Resident 1 sustained a fractured hip, and subsequently passed away on 12/21/2022. Based on interviews which were conducted by Department of Social Services staff, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED
Continued....
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
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
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2023 and conducted by Evaluator Sarah Hurt
COMPLAINT CONTROL NUMBER: 24-AS-20230111113614

FACILITY NAME:GUARDIAN ANGEL HOME CARE IIFACILITY NUMBER:
247203432
ADMINISTRATOR:SILVEIRA, LIDIAFACILITY TYPE:
740
ADDRESS:194 CLIPPER COURTTELEPHONE:
(209) 605-5239
CITY:ATWATERSTATE: CAZIP CODE:
95301
CAPACITY:6CENSUS: 4DATE:
05/03/2023
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Facility staff, Socorro RamirezTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Questionable death
Resident sustained unexplained injuries while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced facility visit to deliver findings on a complaint investigation. LPA Hurt met with facility staff, Socorro Ramirez and explained the purpose of today's visit.

Regarding the allegation Questionable death. On 11/01/2022, Resident 1 began receiving hospice services. On 11/29/2022, Resident 1 sustained a fall while in the facility restroom that resulted in a fracture. Resident 1 passed away on 12/21/2022, at skilled nursing facility. Resident 1’s Death Certificate indicates cause of death was Alzheimer's Disease. Therefore, there is no indication that the fall resulted in death. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 24-AS-20230111113614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GUARDIAN ANGEL HOME CARE II
FACILITY NUMBER: 247203432
VISIT DATE: 05/03/2023
NARRATIVE
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Continued...

Regarding the allegation resident sustained unexplained injuries while in care. LPA Hurt reviewed Bristol Hospice records dated 11/01/2022 through 11/29/2022. The hospice records logged detailed "Narrative Notes" from each visit to the facility with Resident 1. There was no unexplained injuries documented or observed by hospice care staff during this time frame outside of the fall described on 11/29/2022.. Based on interviews conducted, documentation obtained and reviewed during this investigation by Department of Social Services staff this allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No Deficiencies Cited Today Per Tittle 22 Regulations

Exit interview conducted with facility staff, Socorro Ramirez and a copy of this report provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 24-AS-20230111113614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GUARDIAN ANGEL HOME CARE II
FACILITY NUMBER: 247203432
VISIT DATE: 05/03/2023
NARRATIVE
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..Continued

Regarding the allegation Staff did not seek medical attention to resident in a timely manner. Resident 1 fell in the facility bathroom on 11/29/2022 and was not sent to the hospital for treatment until the next day 11/30/22. Hospital records reviewed confirm Resident 1 sustained a fractured hip as a result of the fall on 11/29/2022. Based on interviews which were conducted by Department of Social Services staff, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED


The following deficiencies are being cited (see LIC 9099D) from the California Code of Regulations, Title 22, and California Health and Safety Code. This incident is currently under review and a future civil penalty may apply based on 1569.49(f) H&S. Failure to correct the deficiencies may also result in civil penalties. Exit interview conducted with facility staff Socorro Ramirez and appeal rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 24-AS-20230111113614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO ASC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GUARDIAN ANGEL HOME CARE II
FACILITY NUMBER: 247203432
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
HSC
1569.2(c)
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1569.2(c) “Care and supervision” means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care. The following requirement has not been met as evidenced by:
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Licensee agrees to conduct staff training on 'Care and Supervision" and submit proof to LPA by POC date 05/04/2023.
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Based on interviews conducted facility staff was informed by hospice stafff, Resident 1 was a fall risk and should not be left alone. Staff 1 left Resident 1 alone while on the commode resulting in Resident 1 falling and fracturing their hip, which poses an immediate health, safety, or personal rights risk to residents in care.

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Type A
05/04/2023
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care(a)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. The following requirement has not been met as evidenced by:
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Licensee will conduct training with facility staff on "Incidental Medical and Dental" and "timely medical care" send proof to LPA Hurt by POC date of 05/04/2023.
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Resident 1 fell in the facility restroom on 11/29/2022, and was not taken to the hospital for care until the next day 11/30/2022, which poses an immediate health, safety, or personal rights risk to residents in care.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5