415600897-6-22-2022-14-AS-KHOS-CG9H9N-20220712060014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600897
Report Date: 06/22/2022
Date Signed: 06/22/2022 10:08:30 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/25/2022 and conducted by Evaluator Jaime Vado

COMPLAINT CONTROL NUMBER: 14-AS-20220325155315

FACILITY NAME:	REDWOOD ACRES RESIDENTIAL HOME		FACILITY NUMBER:	415600897
ADMINISTRATOR:	SARMIENTO, ANNA MARISSA V.		FACILITY TYPE:	740
ADDRESS:	1728 REDWOOD AVENUE		TELEPHONE:	(650) 361-1014
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	6	CENSUS: 5	DATE:	06/22/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Carlos Ordonez		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Resident sustained pressure injury while in care.

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado and Kevin Varilla conducted an unannounced complaint investigation visit to deliver the findings of the above allegation. LPA met with caregiver Carlos Ordonez and explained purpose of today's visit.

During the course of the investigation interviews were conducted, resident medical records were reveiwed, and facility records are reviewed. It was found that the resident's wound was discovered by facility staff on 3/12/2022 and was seen by the residen't PCP on 3/15/2022. The PCP recommended home health to care for the recovery of the wound. PCP described the injury as occurring naturally due to skin break down to the foot. Home health provided care to the foot and did not give the facility specific instructions to the staff besides elevation. The allegation is unfounded.

This agency has investigated the complaint alleging residen sustained pressure injury while in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Report is reviewed with Carlos.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022

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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