496803537-9-22-2022-21-AS-KMOA-CJPPQX-20220928113148

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496803537
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:08:20 PM

Unsubstantiated

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
07/21/2022 and conducted by Evaluator David Leibert

COMPLAINT CONTROL NUMBER: 21-AS-20220721081852

FACILITY NAME:	KENWOOD GREENS		FACILITY NUMBER:	496803537
ADMINISTRATOR:	VEGVARY, JULIUS		FACILITY TYPE:	740
ADDRESS:	340 GREENE STREET		TELEPHONE:	(707) 483-0998
CITY:	KENWOOD	STATE: CA	ZIP CODE:	95452
CAPACITY:	8	CENSUS: 5	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mreceedes Vegvary		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Facility retained a resident with a prohibited condition

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert arrived unannounced for the purpose of delivering findings on this complaint. LPA met with the Administrator and discussed the allegation. R1 was sent out via 911 on 07/20/22 from facility. Arriving at the ER, R1 presented with two sacral pressure injuries, stage ll and Unstageable. It has been alleged that, although prohibited by Title Twenty-Two regulations, facility retained R1 with Unstageable pressure injury. An investigation ensued by this Department which included review of photographs; statements taken from witnesses and staff; review of medical and other documents. The following determinations are made: When seen in a medical setting on 7/10, R1 had no noted pressure injuries; During the 3 days proceeding 7/20, staff and witness report R1 had only a small red area on skin in sacral area; Hearsay statements from medical practitioner suggest the injury was several weeks old by 7/20; Opinion expressed by one of the ER physicians reports that it is difficult to gage age of injury in R1 due to R1's fragile and severely malnourished state. Although the allegation may be true, based on statements and documents, there is not a preponderance of evidence to prove the allegation is true. Therefore, the allegation is UNSUBSTANTIATED. Report left. No citations issued.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

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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