496801890-4-5-2021-21-AS-BMOS-C24UBJ-20210415152622

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496801890
Report Date: 04/02/2021
Date Signed: 04/05/2021 08:29:32 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
12/18/2020 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201218124712

FACILITY NAME:	PENNGROVE SHANGRI-LA		FACILITY NUMBER:	496801890
ADMINISTRATOR:	BACANI, MARIA CORAZON		FACILITY TYPE:	740
ADDRESS:	1762 WEISS LANE		TELEPHONE:	(707) 795-7921
CITY:	PENNGROVE	STATE: CA	ZIP CODE:	94951
CAPACITY:	6	CENSUS: 4	DATE:	04/02/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Mary Quiambao - staff		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Facility staff did not provide meals to a resident.

Facility staff did not provide assistance in bathing a resident.

Facility staff did not provide bedding change for a resident.

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegations listed above. Licensing Program Analyst Fernandes-Goes arrived announced for the purpose of closing the investigation and met with staff Mary Quiambao and deliveried complaint findings on the phone to Cora Bacani – Administrator.
On 11/23/2020, LPA Fernandes-Goes conducted interviews, reviewed files, acquired documentation; and made observations of the facility. During documentation review on file, and interviews with complainant, LTCO, Hospice, and staff on 11/23/20, 3/12, 3/18, 3/19, and 3/30/2021 regarding facility procedures and resident R1, LPA learned that facility resident R1 on hospice, able to eat meals without help, continent, non-ambulatory – used a walker, and with a diagnostic of “acute non-st segment elevation myocardial infection as per physician’s assessment dated October 20,2020.
Continue LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

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-20201218124712

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: PENNGROVE SHANGRI-LA	FACILITY NUMBER: 496801890
	VISIT DATE: 04/02/2021

NARRATIVE

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Per hospice documentation and interviews, resident R1 was receiving hospice services twice a week which included hospice nurse, home care aid, and social worker. (copies on file) In addition, according with hospice plan facility was to provide all needed care during the hours that hospice staff wasn’t present including but not limited to showers, change of bedding and clothes, food and support when using bathroom. Interviews acknowledge that resident R1 was found at times in need of bathing and duty bedding. Meals were being provided to resident by the facility, however; at times resident would take longer to eat meals. During this time 2 caregivers were hospitalized due to COVID-19 and there is no certainty that services were being provided as expected by admissions and hospice agreement. Based on LPA interviews and documentation file review, even though allegations might be true, LPA wasn’t able to prove or disprove the complaint allegations.

A finding that the complaint allegations of “Facility staff did not provide meals to a resident.”; “Facility staff did not provide assistance in bathing a resident.”; and “Facility staff did not provide bedding change for a resident.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2021

LIC9099 (FAS) - (06/04)

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