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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 075601538
Report Date: 08/09/2023
Date Signed: 08/09/2023 02:29:14 PM


Document Has Been Signed on 08/09/2023 02:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:CARNELIAN IIIFACILITY NUMBER:
075601538
ADMINISTRATOR:GRUTAS, JAYFACILITY TYPE:
740
ADDRESS:2374 WARREN ROADTELEPHONE:
(925) 938-0200
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94595
CAPACITY:6CENSUS: 5DATE:
08/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Care Coordinator Jio AlonzoTIME COMPLETED:
02:40 PM
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On 08/09/2023 at 9:40 AM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct a Case Management visit concerning the 08/07/2023 unwitnessed fall that resulted in the death of R1 that was reported to the Department in a Death Report dated 08/08/2023. Upon entry, LPA stated the purpose of the visit to Care Coordinator (CC) Jio Alonzo.

During the inspection, the LPA observed R1's room, interviewed staff CC Alonzo and Administrator Jay Grutas (who was present during the incident). LPA also reviewed R1 and facility files. It was staff change time when the incident occurred, so a full complement of direct care staff members were present, at least 8. At the time of R1's fall at 7:09 PM, staff were following facility protocol for residents at a high-risk of falling: half bed rail, elevated legs, fall mat, and both a bed and motion alarm in the room. Staff member S1 was in R1's room within a minute of the alarms being triggered, providing first aid. Immediately thereafter, staff member S2 called 911. Then, they notified R1's Attorney-In-Fact and physician. By 7:15 PM, the fire department and paramedics were in R1's room caring for him. By 7:40 PM, the first responders had departed for John Muir Hospital with R1.

Based upon the data collected from the interviews, file reviews, and facility observations, the staff and administration of the facility operated in accordance with Title 22 regulations and in the best interest of resident R1 before, during, and after R1's unwitnessed fall that caused a break in his cervical vertebrae and ultimately his death on 08/08/2023.

No citations were issued during this inspection.

Exit interview conducted with CC Jio Alonzo. A copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: James SampairTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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