486801989-10-6-2021-21-AS-KMOA-C7LQAF-20211008115952

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486801989
Report Date: 10/06/2021
Date Signed: 10/06/2021 10:01:05 AM

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
02/05/2021 and conducted by Evaluator Christopher Arnhold

COMPLAINT CONTROL NUMBER: 21-AS-20210205143924

FACILITY NAME:	BENICIA ANGEL'S HOME 2 INC.		FACILITY NUMBER:	486801989
ADMINISTRATOR:	BAYON, EVELYN		FACILITY TYPE:	740
ADDRESS:	116 CARLISLE WAY		TELEPHONE:	(707) 748-0482
CITY:	BENICIA	STATE: CA	ZIP CODE:	94510
CAPACITY:	6	CENSUS: 0	DATE:	10/06/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Evelyn Bayon		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Resident developed a pressure injury while in care.
Facility staff are not properly trained.
Facility overcharged resident's responsible party.
Staff did not meet resident's needs.
Resident sustained an unwitnessed fall resulting in a head injury.

INVESTIGATION FINDINGS:

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At approximately 9:00AM, Licensing Program Analyst (LPA) Chris Arnhold arrived at Benicia Angels Home 1, due to Benicia Angels Home 2 being vacant and currently in escrow. This visit is to deliver investigation findings for the above allegations. LPA met with Administrator Evelyn Bayon. The following is a summary of findings for the allegations listed above. R1 was bedridden and on Hospice. The pressure injury was within the parameters of Title 22 regulation. The care was addressed in the hospice care plan. LPA reviewed staff training records and found documentation of the required ongoing training. Resident admission agreement outlines that charges will continue until resident belongings are removed. Receipts for the pickup of medical equipment by the contracted company and documentation of a refund issued to responsible party were in the files reviewed. Based on records reviewed and interviews conducted, resident did sustain a fall while at the facility. 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: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

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-20210205143924

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: BENICIA ANGEL'S HOME 2 INC.	FACILITY NUMBER: 486801989
	VISIT DATE: 10/06/2021

NARRATIVE

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Staff contacted medical personnel in a timely manner and resident was taken to the emergency room. Resident was not on 1 to 1 observation and there was no documentation from the physician that the resident required constant supervision. Resident attempted to move about without the aide of staff, which resulted in a fall. Based on documents reviewed, facility staff contacted emergency personnel to ensure the medical needs of the resident were met in a timely manner. Staff observed that resident was exhibiting symptoms and requested a Covid test be performed. LPA reviewed communications between the facility and residents physician regarding a cough. The physician ordered a cough syrup and recommended a Covid test. Facility scheduled a test through CVS, but ended up having Public Health come to facility to conduct the test because the soonest test was in 6 days. Based on records reviewed, facility followed recommendations from physician and scheduled a Covid test.

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.

No citations issued.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Christopher Arnhold	TELEPHONE: (707) 588-5084
LICENSING EVALUATOR SIGNATURE:	DATE: 10/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021

LIC9099 (FAS) - (06/04)

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