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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 480110389
Report Date: 09/25/2020
Date Signed: 10/07/2020 01:53:00 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200512104026
FACILITY NAME:PARKSIDE MANORFACILITY NUMBER:
480110389
ADMINISTRATOR:GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LANETELEPHONE:
(707) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 14DATE:
09/25/2020
UNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Cecilia GanzonTIME COMPLETED:
12:58 PM
ALLEGATION(S):
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Facility failed to seek timely medical attention for resident.

INVESTIGATION FINDINGS:
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Licnesing Program Analyst (LPA) A. Canela contacted Licensee/Administrator at Parkside Manor Facility by phone and Virtual visit on 9/25/2020 for the purpose of delivering findings on a complaint investigation 21-AS-20200512104026. Due to COVID – 19 precautions/restrictions, a facility visit is not able to be conducted at this time.

The Department conducted a complaint investigation regarding the allegation received for, facility failed to seek timely medical attention for resident. Hospital Medical and other records were requested by the department and reviewed. Statements were taken from
facility staff, and resident R1's family.
On 5/8/2020, around 0730 hours resident R1 sustained an unwitnessed fall while in their bedroom. Facility policy states, any unwitnessed fall with complaints of pain, the resident must be sent out to receive medical attention. Facility staff informed R1 he would be transported to the hospital, but R1 refused. Facility staff called R1’s daughter, identified as I1, to inform her of the fall and to inform her, R1 would be transported to the hospital. I1 refused the hospital transfer and requested she transport R1 herself.
Continue report see LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
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
Control Number 21-AS-20200512104026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 480110389
VISIT DATE: 09/25/2020
NARRATIVE
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About two hours had passed and I1 had not arrived at the facility to transfer R1. Facility staff followed up with I1 to see when she would get to the facility. I1 stated she would transport R1 to the hospital the following day. On 5/9/2020, I1 arrived at the facility, dropped off medications, then left without R1. Facility staff never called EMT, and R1 was transported to the hospital by ambulance on 5/10/2020, by the request of R1’s stepdaughter, identified as I2. The facility failed to follow their own policy resulting in R1 remaining at the facility for two more days with a broken hip after R1's unwitnessed fall. Per Sutter hospital, R1 was diagnosed with a broken hip on 5/10/2020 and passed away on 5/12/2020, due to Cardiac Arrest, Sepsis, Community Acquired Pneumonia, Failure to Thrive, Dementia.

R1 moved to this facility, Parkside Manor in March 2020, R1’s physician's report dated 3/6/2020, shows R1 with Dementia diagnoses, and in Good Physical Health Status. Prior to R1’s fall, facility reported R1’s behavior had changed, R1 was observed to be confused and agitated, did not sleep enough and was restless. Hospital staff records show, R1 disclosed he was placed in bed 5/8/2020, after the fall, and had not been able to get out of bed or ambulate since. Hospital also documented, R1 had increased pain with movement. Through record review and interviews it was confirmed the facility failed to seek medical attention for the resident in a timely manner.

Based on information received, records reviewed, and statement gathered, the above allegation is SUBSTANTIATED. A SUBSTANTIATED finding means the preponderance of evidence standard has been met.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
A civil Penalty for $500.00 is being applied for Health and Safety Code1569.49(c)(1) for regulation 1569.269(a)(6) “The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49 (f).
Appeal Rights were provided and signature on this report acknowledges receipt.

During investigation, LPA found areas of none compliance by the facility that will need to be addressed in a separate report.
This report was emailed to facility to obtain signature.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20200512104026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 480110389
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/25/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/26/2020
Section Cited
HSC
1569.269(a)(6)
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1569.269(a)(6) Enumerated rights; severability
To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidenced by:
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Licensee agrees to provided training from outside source to all staff and licensee regarding care and supervision/ observation of a resident & submit training date to CCL by POC 9/26/2020, submit proof of training to CCL by POC 10/9/2020
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Based on the Department's interviews and record review the facilities neglect resulted in R1, Not receiving medical attention for 2 days after an unwitnessed fall that resulted in hip fracture for R1. R1 came in to the hospital and was also said to have severe Sepsis and with a Pneumonia. which poses an immediate health and safety risk to residents in care.
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An immediate civil penalty in the amount of $500.00 is issued today for the violation of a regulation resulting in injury or illness. 1569.49(c)(1)
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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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/12/2020 and conducted by Evaluator Araceli Canela
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20200512104026

FACILITY NAME:PARKSIDE MANORFACILITY NUMBER:
480110389
ADMINISTRATOR:GANZON, CECILIAFACILITY TYPE:
740
ADDRESS:50 CADLONI LANETELEPHONE:
(707) 557-8991
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:17CENSUS: 14DATE:
09/25/2020
UNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Cecilia GanzonTIME COMPLETED:
12:58 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident being hospitalized
INVESTIGATION FINDINGS:
1
2
3
4
5
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7
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9
10
11
12
13
Licnesing Program Analyst (LPA) A. Canela contacted Licensee/Administrator at Parkside Manor Facility by phone and Virtual visit on 9/25/2020 for the purpose of delivering findings on a complaint investigation 21-AS-20200512104026. Due to COVID – 19 precautions/restrictions, a facility visit is not able to be conducted at this time.

The Department conducted a complaint investigation regarding the allegation received for, staff neglect resulted in resident being hospitalized Hospital Medical and other records were requested by the department and reviewed. Statements were taken from facility staff, and resident R1's family. Per facility notes, on 3/8/2020, R1 moved in to the this facility. On 3/18/2020, the facility requested R1's family update R1's medications. On 4/22/2020, R1's daughter (I1) dropped off medications. On 4/23/2020, the facility notified R1's family R1 did not obtain all the medications. On 5/7/2020, the facility called R1's physician (D1) for new medication to aid in R1's sleeping and D1 prescribed medication for agitation during bedtime.
Continue report see LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20200512104026
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: PARKSIDE MANOR
FACILITY NUMBER: 480110389
VISIT DATE: 09/25/2020
NARRATIVE
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Continued report for allegation: Staff neglect resulted in resident being hospitalized

Facility notified the pharmacy and I1 dropped off the medications on 5/9/2020.
Facility reported, R1 was having trouble sleeping while at the facility and ordered more medications. A few days before R1 fell, R1 ran out of medication which helped R1 sleep. It was reported the night before R1 sustained his fall, he did not sleep. R1 fell asleep in the early morning hours. The facility state they allowed R1 to continue sleeping since R1 had trouble sleeping the night before. While the facility residents were having breakfast on 5/8/2020 around 0730 hours, the staff heard a loud noise and staff found R1 on the floor. R1 had not been deemed a fall risk per R1s Physician's report. R1 used a wheelchair to get around facility.

The Department has investigated the above allegation for staff neglect resulted in resident being hospitalized and determined, 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 above allegation is Unsubstantiated.

No citations issued for this report.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 5