486801821-6-23-2020-21-AS-CMAZ-BQUUUW-20200623155413

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801821
Report Date: 06/23/2020
Date Signed: 06/23/2020 03:27:24 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
01/09/2020 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20200109163543

FACILITY NAME:	ANN'S CARE HOME		FACILITY NUMBER:	486801821
ADMINISTRATOR:	BEST, DEBRA ANN		FACILITY TYPE:	740
ADDRESS:	124 DELTA CIRCLE		TELEPHONE:	(707) 643-3363
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	5	CENSUS: 1	DATE:	06/23/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee, Debra Best		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Severe neglect resulted in a resident obtaining sepsis while in care
Staff neglect resulted in resident developing multiple pressure injuries while in care

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2020

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 3

Control Number 21-AS-20200109163543

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: ANN'S CARE HOME	FACILITY NUMBER: 486801821
	VISIT DATE: 06/23/2020

NARRATIVE

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Continued from LIC9099

Complaint alleged that staff neglect resulted in resident, R1 developing multiple pressure injuries while in care. Resident was on hospice care since January 2019. While on hospice, interviews and documentation show that R1 experienced multiple pressure wounds and general decline in health. Witness interviews indicated that because R1 was terminal, their body was unable to heal the wound(s). Witnesses who helped provide care for R1 did not observe evidence of neglect from care staff and indicated that the resident was always clean and dry, staff was using barrier cream and resident was turned per Hospice instruction.

The Department has investigated the complaint allegation that severe neglect resulted in resident obtaining sepsis while in care and that staff neglect resulted in resident developing multiple pressure injuries 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.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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
01/09/2020 and conducted by Evaluator Victoria Willis

COMPLAINT CONTROL NUMBER: 21-AS-20200109163543

FACILITY NAME:	ANN'S CARE HOME		FACILITY NUMBER:	486801821
ADMINISTRATOR:	BEST, DEBRA ANN		FACILITY TYPE:	740
ADDRESS:	124 DELTA CIRCLE		TELEPHONE:	(707) 643-3363
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94589
CAPACITY:	5	CENSUS: 1	DATE:	06/23/2020
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Licensee, Debra Best		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Due to staff neglect, resident is not being provided an adequate amount of fluids while in care

INVESTIGATION FINDINGS:

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LPA Willis conducted a Televisit with Licensee, Debra Best to deliver findings regarding the above mentioned allegations.

During the investigation, the Department conducted interviews with staff and witnesses, reviewed documents and photographs and made observations. Complaint alleges that due to staff neglect, resident (R1) is not being provided an adequate amount of fluids while in care. Interview with Licensee indicated that R1 was provided water, apple juice and a protein drink at each meal. Licensee indicated that they would pull up R1’s skin each day to help determine if resident was dehydrated and stated that R1 was not dehydrated until the end. Other caregivers indicated that resident was good about drinking water. Witness interview indicated that R1 always had water next to their bedside.
The Department has determined that the complaint allegation that due to staff neglect, resident is not being provided an adequate amount of fluids while in care was unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegation occurred. We have therefore dismissed the complaint.
No deficiencies cited during this inspection.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Willis	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2020

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 3