486803614-3-12-2021-21-AS-KMOA-BZ7VAX-20210317161636

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803614
Report Date: 03/12/2021
Date Signed: 03/12/2021 05:18:32 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
11/12/2020 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201112125549

FACILITY NAME:	OAKWOOD MEMORY & SENIOR CARE		FACILITY NUMBER:	486803614
ADMINISTRATOR:	ESTHER ZELEDON		FACILITY TYPE:	740
ADDRESS:	1025 OAKWOOD AVENUE		TELEPHONE:	(707) 643-0473
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	30	CENSUS: 10	DATE:	03/12/2021
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Theresa iLagan"TJ"		TIME COMPLETED:	01:26 PM

ALLEGATION(S):

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Resident sustained injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) A. Canela contacted Teresa iLagan "TJ", care staff/manager at Oakwood Memory & Senior Care Facility by telephone on 3/12/2021 for the purpose of delivering findings on complaint investigation 21-AS-202011121255498. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

It was alleged resident sustained injuries while in care, more specifically, that Resident R1 was pushed by resident R2 during an altercation and R1 fell to the floor and may have been kicked by R2 as R1 had a bruise on the back of the thigh. During the investigation, LPA reviewed/obtained records, made facility observations via tele-visit, and conducted interviews with facility staff. LPA was unable to obtain a statement from complainant due to complainant not returning voicemail messages left on 11/20, 11/23/2020 and 3/3/2021. LPA interviewed several staff and investigation revealed the incident was not observed. Several statements were made, R1 had stated R2 had pushed R1 and that R2 stated R1 hit him from behind while he was sitting and, R1 ran and fell on their own.
Continue report - see LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

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-20201112125549

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: OAKWOOD MEMORY & SENIOR CARE	FACILITY NUMBER: 486803614
	VISIT DATE: 03/12/2021

NARRATIVE

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There were no witnesses to the incident and no one heard any altercation. Staff were facing on the other direction and saw R2 sitting and R1 behind on the floor. R1 was said to have reported no pain or injuries at the beginning and then stated they had pain and were sent off to the hospital, where they were discharged the same day. Resident was removed from facility by family and no records were received regarding resident injuries.
There were no corroborating statements made. Although the resident did sustain a fall, there was no indication how the incident actually happened or evidence they were pushed or kicked while on the floor, by R2 as the reporting party is referring to, additionally no medical records were provided to LPA and R1 was removed from the facility by responsible party shortly after the incident. The Department has investigated the above allegations and at this time determined, although the allegations may have happened or are 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 allegation. This report was emailed to facility to obtain signature.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2021

LIC9099 (FAS) - (06/04)

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