286804070-4-22-2024-21-AS-BMOS-D53UVQ-20240508155532

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 286804070
Report Date: 04/22/2024
Date Signed: 04/22/2024 11:51:28 AM

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
01/03/2024 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20240103123250

FACILITY NAME:	AGING IN THE BAY 3		FACILITY NUMBER:	286804070
ADMINISTRATOR:	MENDAROS, CHARMAINE		FACILITY TYPE:	740
ADDRESS:	1088 DONALDSON WAY		TELEPHONE:	(510) 388-7352
CITY:	AMERICAN CANYON	STATE: CA	ZIP CODE:	94503
CAPACITY:	6	CENSUS: 4	DATE:	04/22/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Charmaine Mendaros		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not provide medical attention to resident’s pressure sore.
Staff did not administer resident’s medication as prescribed.
Staff not assisting resident in a timely manner.
Staff does not provide bell within reaching distance for resident.
Staff does not provide a comfortable environment for resident.

INVESTIGATION FINDINGS:

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At approximately 9:15AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at this facility unannounced, to conduct an investigation into the above allegations. LPA met with caregiver Angelina Manabat, toured the facility and reviewed records. Administrator Charmaine Mendaros arrived a short time later. Based on records reviewed and interviews conducted, Resident, R1, moved into this facility from the Hospital and was under the care of Solano Hospice. Based on hospice care plan and interviews conducted, a hospice aide came to the facility daily to care for R1's wound. LPA reviewed medication records and observed facility utilizes a medication administration record, MAR, and the form indicated medications were given as ordered. R1 resided in the facility for approximately seven days and based on care plan and assessment, was able to communicate their needs. There was no indication resident was not assisted in a timely manner. Continued on LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

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-20240103123250

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: AGING IN THE BAY 3	FACILITY NUMBER: 286804070
	VISIT DATE: 04/22/2024

NARRATIVE

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Based on interviews conducted, LPA was not able to verify whether resident call bell was within reach. Facility procedures are to place bell next to bed within reach.
LPA observed facility to be at a comfortable temperature at each visit. LPA toured the building and observed residents had the required accommodations. LPA did not observe anything in the facility that would make for an uncomfortable environment.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2024

LIC9099 (FAS) - (06/04)

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