486803265-2-16-2021-21-AS-BMOS-BYJQBH-20210224110134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803265
Report Date: 02/11/2021
Date Signed: 02/16/2021 01:22:59 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
03/13/2020 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200313173815

FACILITY NAME:	NENE'S REST HOME		FACILITY NUMBER:	486803265
ADMINISTRATOR:	EVELYN CHAN		FACILITY TYPE:	740
ADDRESS:	2968 VISTA GRANDE		TELEPHONE:	(707) 425-7522
CITY:	FAIRFIELD	STATE: CA	ZIP CODE:	94534
CAPACITY:	6	CENSUS: 3	DATE:	02/11/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	MaryJane Miranda		TIME COMPLETED:	03:46 PM

ALLEGATION(S):

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Staff did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) A. Canela contacted MaryJane Miranda, Administrator/ caregiver at Nene's Rest Home Facility by telephone on 2/11/2021 for the purpose of delivering findings on a complaint investigation 21-AS-20200313173815. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

LPA received statements and gathered records. It was alleged facility staff did not seek medical attention in a timely manner. It was reported paramedics were called for resident R1 who was said to have been showing signs of weakness. Facility staff disclosed R1 had been complaining of shoulder & leg pain for a week, appeared to have all over body weakness the last few days, but still appeared fine, R1 could eat and talk, just needed more assistance in the past week. R1 was said to have had a fall in January 2020 and was to follow up with R1's Physician. Facility staff explain they made several attempts for R1's responsible party regarding the need for R1 to follow up. Staff reported they were in communication with R1's family regarding R1's condition and after several calls, the family came to see R1 and agreed to call 911.

Continue report see LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

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-20200313173815

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: NENE'S REST HOME	FACILITY NUMBER: 486803265
	VISIT DATE: 02/11/2021

NARRATIVE

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Paramedics disclosed to LPA, they found R1 to have stroke like symptoms, when they moved the residents blanket they observed R1's left arm, not moving, the resident was unable to grip, had zero grip. Paramedics were informed by facility staff that this has been going on for a week as well. It was also disclosed by Paramedics, R1 had UTI like symptoms, with a strong ammonia smell in the room and R1 also disclosed, burning sensation.
Investigation revealed, facility staff failed to call 911 or send R1 to be seen by R1's physician. Staff stated they felt they needed to get approval from R1's responsible party and there for did not seek medical attention in a timely manner. Emergency responders were called by R1's family member after they agreed with staff to come see R1 regarding the symptoms.

Based on the above information the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights were provided and signature on this report acknowledges receipt.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200313173815

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: NENE'S REST HOME	FACILITY NUMBER: 486803265
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/11/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/12/2021 Section Cited HSC 1569.269(6)	1 2 3 4 5 6 7	1569.269(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.	1 2 3 4 5 6 7	Facility to send in a written plan on how they will meet regulation, along with staff training.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Facility failed to notice the changes for R1, call 911 or send R1 to be seen by a doctor. This is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	POC due date: 2/12/2021 To LPA Araceli Canela (707)588-5080 or email araceli.canela@dss.ca.gov
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021

LIC9099 (FAS) - (06/04)

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