079200569-5-23-2023-15-AS-HHUL-CWRV6E-20231019160927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200569
Report Date: 05/23/2023
Date Signed: 05/23/2023 03:19:12 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220830094419

FACILITY NAME:	PLEASANT HILL VILLA HOME CARE		FACILITY NUMBER:	079200569
ADMINISTRATOR:	M. ELAZEGUI & G. MAGAT		FACILITY TYPE:	740
ADDRESS:	3021 PUTNAM BLVD		TELEPHONE:	(408) 933-8663
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Gliceria Magat, Licensee/Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff does not have the required training to meet resident needs

INVESTIGATION FINDINGS:

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On 5/23/2023 at 1:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver findings in regards to the allegation above. LPA met with Licensee/Administrator, Gliceria Magat.

During the course of investigation, LPA interviewed 1 resident, 5 staff, and complainant. LPA obtained and reviewed documents including physician's report, care plan, hospice records, medical records, MAR, list of medications, incident reports, and staff training. Training documents shows that staff did not complete annual 20 hours of training in 2021 and 2022.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 15-AS-20220830094419

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PLEASANT HILL VILLA HOME CARE	FACILITY NUMBER: 079200569
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/09/2023 Section Cited HSC 1569.625(b)(2)	1 2 3 4 5 6 7	Staff training; legislative findings; contents. In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training...This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator has agreed to conduct annual training to all staff and submit completion documents to CCLD by POC date.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not completing annual training for staff which poses a potential health and safety risk to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2022 and conducted by Evaluator Grace Luk

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220830094419

FACILITY NAME:	PLEASANT HILL VILLA HOME CARE		FACILITY NUMBER:	079200569
ADMINISTRATOR:	M. ELAZEGUI & G. MAGAT		FACILITY TYPE:	740
ADDRESS:	3021 PUTNAM BLVD		TELEPHONE:	(408) 933-8663
CITY:	PLEASANT HILL	STATE: CA	ZIP CODE:	94523
CAPACITY:	6	CENSUS: 6	DATE:	05/23/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Gliceria Magat, Licensee/Administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not follow proper feeding procedures which resulted in the resident being hospitalized.
Staff did not assist the resident as needed with ambulating which resulted in the resident becoming bruised.
Staff did not assist the resident as needed with medications.

INVESTIGATION FINDINGS:

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On 5/23/2023 at 1:20PM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver findings in regards to the allegations above. LPA met with Licensee/Administrator, Gliceria Magat.

During the course of investigation, LPA interviewed 1 resident, 5 staff, and complainant. LPA obtained and reviewed documents including physician's report, care plan, hospice records, medical records, MAR, list of medications, incident reports, and staff training.

Staff did not follow proper feeding procedures which resulted in the resident being hospitalized.
R3 was admitted to John Muir on 6/26/2022 due to trouble breathing. Physician's report dated 5/11/2022 does indicate that R3 can self-feed and no special diet. Interview with staff revealed that R3's private caregiver provided assistance in feeding. (Continue on LIC9099C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20220830094419

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PLEASANT HILL VILLA HOME CARE	FACILITY NUMBER: 079200569
	VISIT DATE: 05/23/2023

NARRATIVE

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Staff did not assist the resident as needed with ambulating which resulted in the resident becoming bruised.
Physician's report dated 5/11/2022 does indicate that R3 is ambulatory. Pre-placement appraisal states that R3 is non-ambulatory and uses a walker. Interview with staff revealed staff assist residents in ambulating.

Staff did not assist the resident as needed with medications.
Interview with staff revealed there was a medication with instructions to hold if R3 will be laying down. Staff stated the medication was not given when R3 was laying down.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4