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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700554
Report Date: 03/02/2021
Date Signed: 03/02/2021 04:52:32 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2020 and conducted by Evaluator Angela Hood
COMPLAINT CONTROL NUMBER: 27-AS-20200702123036
FACILITY NAME:ANGIES CARE HOMEFACILITY NUMBER:
342700554
ADMINISTRATOR:CRUDO, ANGELINAFACILITY TYPE:
740
ADDRESS:8558 SHERATON DRTELEPHONE:
(916) 962-2460
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY:6CENSUS: 5DATE:
03/02/2021
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Angie Crudo, AdministratorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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-Facility did not ensure resident's oxygen tank is full
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angela Hood contacted the Administrator, Angie Crudo, via phone, due to COVID-19 and precautionary measures, to deliver findings into the allegations listed above.

Facility did not ensure resident’s oxygen tank is full:

During the course of the investigation, LPA conducted interviews and obtained documentation pertinent to the investigation. Interviews with the relevant party, the Administrator, and according to the resident’s (R1) Preplacement Appraisal Information LIC603, R1 was being seen for dialysis three times per week at a dialysis clinic. The LIC603 also indicates that the resident is oxygen dependent. Interviews with the Administrator, relevant party, and a staff (S1) from the dialysis clinic, indicated R1 was transported to the dialysis appointments with their own personal portable oxygen tank to be used during transport and dialysis treatment.

********************************************Continued on LIC9099-C*************************************************
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
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 4
Control Number 27-AS-20200702123036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554
VISIT DATE: 03/02/2021
NARRATIVE
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According to interviews with the relevant party and S1, R1’s oxygen tank was empty during several dialysis appointments. Interview with S1 indicated that they worked directly with R1 providing dialysis treatment since March 2020 and that every time R1 would arrive for dialysis, R1 would have an empty oxygen tank. According to interview with S1, R1 had a physician’s order requiring oxygen and due to the tank being empty, the dialysis clinic would provide oxygen to R1 during dialysis treatment. However, R1 did not have oxygen for use during transport after dialysis treatment. The interview with S1 and the relevant party indicated that the dialysis clinic attempted to communicate with the Administrator regarding the empty tank. According to the Administrator, there was concern that the dialysis clinic did not know how to use the oxygen tank that was provided for R1 during their dialysis treatment. The interview with S1 indicated that the dialysis clinic staff are trained to use oxygen tanks and that when S1 had turned R1’s tank on 5, which is as high as it goes, nothing would come out of the tank. According to S1, R1 would be gasping for air upon arrival and departure from dialysis appointments, as R1 did not have a functioning oxygen tank to utilize during transport.

According to interview with the Administrator, R1 has both a home oxygen tank and a portable tank that hooks to the back of R1’s wheelchair. Interview with the Administrator indicated that the oxygen tank company delivered oxygen for R1 every month for 6 months on the 3rd Wednesday of each month. Interview with the Administrator indicated that R1 is the only resident that has resided in the care home that required oxygen without hospice care. According to interview with the Administrator, the oxygen delivery service is the only one she has ever worked with, as typically hospice care services took care of oxygen needs if a resident is on hospice care. Interview with the Administrator indicated that the facility does not have any procedures for obtaining and refilling oxygen, as she would call the oxygen company for R1 if needed. LPA requested documentation from the facility relevant to R1’s oxygen use, such as oxygen refill or delivery receipts and physician’s order for oxygen use and to date LPA has not received documentation.

**********************************************Continued on LIC9099-C*************************************************

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20200702123036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554
VISIT DATE: 03/02/2021
NARRATIVE
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Interview with the representative at the oxygen tank company indicated that deliveries began in August 2019 to the facility for R1’s oxygen tanks. The interview with the representative indicated that there were two deliveries during the month of August with each delivery being two oxygen tanks. According to interview with the representative, each time the delivery service delivers tanks, they replace the same amount of empty tanks with full tanks. The interview with the representative indicated that in September 2019 ten tanks were delivered, in October 2019 another ten tanks, in November 2019 ten more tanks, in December 2019 there were eight tanks delivered, in February 2020 four tanks, in April 2020 eight tanks, and in May 2020 there were eight tanks delivered. According to the representative, delivery services picked up eight tanks from the care home in August 2020 as services were terminated. The interview with the representative indicated that there were four months that oxygen tank deliveries were not made to the care home. Documentation from the facility indicated that R1 was placed on hospice care on 7/10/2020 and R1 expired on 7/13/2020.

Based on interviews conducted by LPA and records reviewed, the preponderance of evidence standards have been met. Therefore, the above allegation is found to be SUBSTANTIATED. Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies are being cited on the attached 9099D.

An exit interview was conducted with the Administrator via telephone and a copy of this report and appeal rights will be provided to the facility via email. This facility shall sign and return a copy of the report to CCLD and print a copy to be retained by the facility.

SUPERVISOR'S NAME: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20200702123036
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: ANGIES CARE HOME
FACILITY NUMBER: 342700554
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/03/2021
Section Cited
CCR
87618(b)(3)(H)
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87618 Oxygen Administration - Gas and Liquid (b) In addition to Section 87611(b), the licensee shall be responsible for the following: (3) Ensuring that the use of oxygen equipment meets the following requirements: (H) Equipment shall be operable.


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The Licensee shall submit a plan for oxygen use and delivery to ensure any residents requiring oxygen have a sufficient supply on hand. The plan should also indicate how staff will be trained on oxygen use for residents.

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This requirement is not met as evidenced by:

Based on interviews conducted and records reviewed, the facility did not ensure resident (R1’s) oxygen tank was full and operable, which posed an immediate health, safety, and personal rights risk to the resident in care.
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Licensee will submit requested document to LPA by POC due date of 3/3/21.
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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: Maribeth SentyTELEPHONE: (916) 263-4813
LICENSING EVALUATOR NAME: Angela HoodTELEPHONE: (650) 676-0390
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4