<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200682
Report Date: 10/12/2020
Date Signed: 10/12/2020 12:55:22 PM



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
11/12/2019 and conducted by Evaluator Celia Phomphachanh
COMPLAINT CONTROL NUMBER: 15-AS-20191112132851
FACILITY NAME:ELDRIDGE CARE HOMEFACILITY NUMBER:
019200682
ADMINISTRATOR:DIZON, MILLICENT RFACILITY TYPE:
735
ADDRESS:26601 ELDRIDGE AVENUETELEPHONE:
(510) 571-1980
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 5DATE:
10/12/2020
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Millicent Dizon, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed pressure injuries while in care.
Staff did not provide medical attention to resident in a timely manner.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On Monday, October 12, 2020 at 9:50 AM, Licensing Program Analyst (LPA), C. Phomphachanh conducted a phone call with Administrator, Millicent Dizon. LPA explained the reason for the call and informed Administrator of the deliverance of this complaint for the above allegations. Due to the Shelter in Place Executive Order by the Governor, LPA was unable to deliver the findings in person.

During the course of investigation, the Department conducted interviews and collected pertinent documents such as Physician Reports, Home Health Notes, Hospital Medical Records, and facility documentation.

Allegation — Resident developed pressure injuries while in care. Beginning in early October 2019, R1 was being treated for left hip pressure injury by a home health nurse. According to interview and medical records, the last day R1 received care from the home health nurse was November 1, 2019.

Continuation on LIC 9099 C - Page 1 of 2 Complaint Investigation Report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
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 6
Control Number 15-AS-20191112132851
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
VISIT DATE: 10/12/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continuation - Page 2 of 2 Complaint Investigation Report ***This is an AMENDED REPORT*****

When the home health nurse contacted the facility to schedule a follow-up visit, the home health nurse reports not receiving a response from the facility. In addition, the facility failed to arrange for the follow-up care for R1. On November 8, 2019, R1 was admitted to the hospital with a stage 4 pressure injury at the sacrum area and a stage 3 pressure injury to the left hip. As result of the facility’s failure to arrange for follow-up care, R1 sustained pressure injuries while in care of the facility. This allegation is SUBSTANTIATED.

Allegation—Facility staff failed to provide timely medical attention to resident. November 1, 2019 was the last day Home Health Nurse provided wound care to R1. Between November 1, 2019 to November 8, 2019, R1 did not receive wound care from the home health nurse. Facility failed to seek medical attention when Home Health Nurse was not available. The Home Health Nurse tried to contact facility in order to care for the wound, however the facility failed to respond. On November 8, 2019, facility staff were changing the dressing to R1’s wound on the buttocks area when they noticed the wound had worsened. Staff notified the Administrator; however, Administrator told staff to wait until Administrator was present to see the wound. When Administrator arrived an hour later, 911 was called and R1 was transported to the hospital. As result, the facility failed to seek timely medical attention for the resident. This allegation is SUBSTANTIATED.

The following deficiencies were found during the course of this investigation:

  1. Care and Supervision, 80078(a) - facility failed to arrange for follow up care resulting R1 in pressure injury.
  2. Care and Supervision, 80078(a) - facility failed to not provide medical care timely.

Based on the Department's observations, interviews conducted, and records reviewed, the above allegations are SUBSTANTIATED. The preponderance of evidence standard has been met. California Code of Regulations, Title 22 citations are being cited on the attached LIC 9099-D.


Exit interview conducted with Administrator, Millicent Dizon. Copy of report and appeals rights sent via email PDF.

Note: Original reported was delivered on 10/12/2020.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 15-AS-20191112132851
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2020
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
***This is an AMENDED REPORT****
80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
1
2
3
4
5
6
7
Administrator will review regulation 80078 with staff. Once reviewed, Administrator will submit a self-certification to CCL with title, name of attendees, and date by POC date 10/23/2020.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Based on observation and record reviewed, facility failed to seek follow up care resulting in pressure injury which poses an immediate health/safety issue for resident in care.
8
9
10
11
12
13
14
Type A
10/23/2020
Section Cited
CCR
80078(a)
1
2
3
4
5
6
7
80078 Responsibility for Providing Care and Supervision
(a) The licensee shall provide care and supervision as necessary to meet the client's needs.
1
2
3
4
5
6
7
Administrator will review regulation 80078 and outline of information that was discussed with staff. Once reviewed, Administrator will submit a self-certification to CCL with title, name of attendees, and date by POC date 10/23/2020.
8
9
10
11
12
13
14
This requirement was not met as evidenced by:

Based on observation and record reviewed, facility failed proivde medical care timely for R1 which poses an immediate health/safety issue for resident in care.
8
9
10
11
12
13
14
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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 15-AS-20191112132851
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2020
Section Cited
CCR
00000
1
2
3
4
5
6
7
****This is an AMENDED REPORT***

There should be no deficiency cited on this report.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
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: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
11/12/2019 and conducted by Evaluator Celia Phomphachanh
COMPLAINT CONTROL NUMBER: 15-AS-20191112132851

FACILITY NAME:ELDRIDGE CARE HOMEFACILITY NUMBER:
019200682
ADMINISTRATOR:DIZON, MILLICENT RFACILITY TYPE:
735
ADDRESS:26601 ELDRIDGE AVENUETELEPHONE:
(510) 571-1980
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:6CENSUS: 5DATE:
10/12/2020
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Millicent Dizon, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained unexplained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On Monday, October 12, 2020 at 9:50 AM, Licensing Program Analyst (LPA), C. Phomphachanh conducted a phone call with Administrator, Millicent Dizon. LPA explained the reason for the call and informed Administrator of the deliverance of this complaint for the above allegations. Due to the Shelter in Place Executive Order by the Governor, LPA was unable to deliver the findings in person.

During the course of investigation, the Department conducted interviews and collected pertinent documents such as Physician Reports, Home Health Notes, Hospital Medical Records, and facility documentation.

Allegation—Resident sustained unexplained injuries. R1 sustained bruising on left elbow and hand swelling. R1 was transported to the hospital on September 6, 2019 with a chief complaint of constipation, left elbow pain, and hand swelling. During the Emergency Room visit, R1 did not have any fracture to the left arm.

Continuation on LIC 9099A-C - Page 1 of 2 Complaint Investigation Report
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 15-AS-20191112132851
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: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682
VISIT DATE: 10/12/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Continuation - Page 2 of 2 Complaint Investigation Report

R1 was diagnosis with left elbow contusion which can caused pain, swelling, and bruising. This may be caused by R1’s previous fall in June 8, 2019 and continuously falls from R1’s bed. R1 develop declining health leading R1 to become a fall risk. Therefore, as result of this allegation, it is UNSUBSTANTIATED.

Based on the Department's observations, interviews conducted, records reviewed, and investigation, this allegation is found to be UNSUBSTANTIATED. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted with Millicent Dizon, Administrator. Copy of report will be sent via email PDF format.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6