486803921-2-7-2023-21-AS-KMOA-CNUU53-20230208141601

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 486803921
Report Date: 02/07/2023
Date Signed: 02/07/2023 09:09:25 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2022 and conducted by Evaluator Araceli Canela

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20220914141115

FACILITY NAME:	LODGE AT GLEN COVE, THE		FACILITY NUMBER:	486803921
ADMINISTRATOR:	SANDOVAL, GRACE		FACILITY TYPE:	740
ADDRESS:	140 GLEN COVE MARINA ROAD		TELEPHONE:	(707) 592-1157
CITY:	VALLEJO	STATE: CA	ZIP CODE:	94591
CAPACITY:	155	CENSUS: 87	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	02:32 PM
MET WITH:	Grace Sandoval		TIME COMPLETED:	04:33 PM

ALLEGATION(S):

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Facility did not provide assistance with resident care needs
Facility did not notify residents responsible party and/or properly addressed residents injury

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), A. Canela arrived unannounced, for the purpose of delivering findings to the above complaint listed allegations. Throughout the investigation, LPA toured the inside of this facility, made observations, requested records and gathered statements.

It was alleged facility did not provide assistance with resident care needs for Dementia resident R1. It was reported R1 was observed on several occasions with their dentures full of stuck on food particles and their hair unkempt. R1 requires assistance with self care. LPA received corroborating statements not all staff provided assistance with oral care for R1. LPA also received copies of pictures that were taken, identifying the lack of daily assistance for R1.
See LIC9099-C for continued report

Substantiated

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: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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-20220914141115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
	VISIT DATE: 02/07/2023

NARRATIVE

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It was also reported facility did not notify residents responsible party and/or properly addressed residents injury. It was reported resident R1 was observed with bandage gauze on their arms and R1's family was not notified of an injury. It was also disclosed the bandages were not changed for several days and there was no documentation the resident was assessed by a medical professional.

Based on LPA’s record review & statements received, the preponderance of evidence standard has been met, therefore, allegations for, "facility did not provide assistance with resident care needs & facility did not notify residents responsible party and/or properly addressed residents injury are both found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20220914141115

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: LODGE AT GLEN COVE, THE	FACILITY NUMBER: 486803921
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/08/2023 Section Cited HSC 1569.269(a)(6)	1 2 3 4 5 6 7	1569.269(a)(6) Enumerated rights; severability(a)Residents of residential care facilities for the elderly shall have all of the following rights:(6) 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 ensure residents are assisted with activities of daily living, that a plan is incorporated to meet their needs and that staff follow. Facility to conduct staff training.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Facility failed to ensure resident R1 was assisted with their oral, self care needs and plan to ensure injuries are assessed. This is an immediate risk to the health and safety of residents in care.	8 9 10 11 12 13 14	Written plan due 2/8/2023 and staff training due by 2/14/2023 attention LPA Araceli Canela by FAX or email.
Type B 02/16/2023 Section Cited CCR 87211(a)((1)	1 2 3 4 5 6 7	87211(a)((1)Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.	1 2 3 4 5 6 7	Facility to send in written plan on how they will ensure they meet requlation.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: facility failed to report R1's arm injuries to family and Community Care Licensing , within 7 day. This is a potential risk to resident in care	8 9 10 11 12 13 14	POC due date 2/16/2023

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: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli Canela	TELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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