079200610-4-29-2021-15-AS-KHOS-C2VM3S-20210510091537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200610
Report Date: 04/29/2021
Date Signed: 04/29/2021 04:43:35 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
04/26/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210426171144

FACILITY NAME:	WOODBRIDGE TRIFARI		FACILITY NUMBER:	079200610
ADMINISTRATOR:	MUTYA, JOHANNA		FACILITY TYPE:	734
ADDRESS:	3240 TRIFARI PLACE		TELEPHONE:	(925) 446-4118
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	4	CENSUS: 4	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Melizza Cortez, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained an injury while in care

INVESTIGATION FINDINGS:

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On 04/29/21 at 12:15PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a tele-visit with administrator (ADM) and explained the purpose of the tele-visit. Due to COVID-19 shelter in place order, administrator was not physically available to sign this report.

During investigation, LPA conducted interviews and gathered information relevant to the above allegation which implies neglect by staff. Based on record reviews and interviews. client's (C1) change in condition was noticed by his 1:1 DSP (S1) on 04/16/21 when they were getting him ready for his ADLs and shower. C1 did not want staff to touch his upper left arm. S1 noticed a slight discoloration/swelling on his upper left arm and when asked if he was in pain, C1 indicated 6/10 from the pain scale. S1 coordinated C1's medical evaluation with his PCP on the same day. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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 15-AS-20210426171144

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: WOODBRIDGE TRIFARI	FACILITY NUMBER: 079200610
	VISIT DATE: 04/29/2021

NARRATIVE

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Based on C1's PCP recommendations, xrays were taken of C1's left arm in the afternoon of 04/16/21 in Urgent Care. C1 was given ibuprofen for pain management with a referral to an orthopedic specialist. Xrays were taken again on C1's left arm and further assessments/Xrays were done by an orthopedic specialist on 04/19/21.

Review of C1's records reveal that since 03/08/21, C1 has engaged in increased physical and occupational therapy activities prior to his left arm injury. C1 was required to use an arm sling to immobilize his left arm and all his physical and occupational therapy activities were placed on hold by his doctors until his left arm heals. Staff did not witness C1 have any incident of a fall, slip, physical aggression or physical contact with other clients. PCPs and staff could not identify cause of C1's injury.

During the tele-visit, LPA observed C1 resting comfortably in his bed wearing a left arm sling. LPA observed C1 was not in any pain with his immobilized left arm. LPA observed C1 to be well groomed, in good spirits and smiled at staff. LPA observed 2 DSPs assisting C1 inside the bedroom.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the allegation that resident sustained injury while in care due to neglect did occur. Therefore, this allegation is UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to administrator via email.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

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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
04/26/2021 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20210426171144

FACILITY NAME:	WOODBRIDGE TRIFARI		FACILITY NUMBER:	079200610
ADMINISTRATOR:	MUTYA, JOHANNA		FACILITY TYPE:	734
ADDRESS:	3240 TRIFARI PLACE		TELEPHONE:	(925) 446-4118
CITY:	CONCORD	STATE: CA	ZIP CODE:	94518
CAPACITY:	4	CENSUS: 4	DATE:	04/29/2021
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Melizza Cortez, Administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not report an incident in a timely manner

INVESTIGATION FINDINGS:

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On 04/29/21, Licensing Program Analyst (LPA) D Panlilio conducted a tele-visit with administrator to deliver the finding. Due to COVID-19 shelter in place order, administrator was not physically available to sign this report. This report supersedes the original report on 4/29/21.

Based on interviews and record reviews, C1’s left arm injury occurred on 04/16/21, but facility did not verbally inform CCLD until 4/20/21 and failed to submit a written report.

Based on the department’s investigation, the allegation that staff did not report an incident in a timely manner is substantiated. There is a preponderance of evidence to prove the alleged violation did occur, therefore this allegation is substantiated.

Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.
Exit interview conducted. Appeal Rights and a copy of this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

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-20210426171144

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: WOODBRIDGE TRIFARI	FACILITY NUMBER: 079200610
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/29/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/31/2021 Section Cited CCR 80061(b)(1)(D)	1 2 3 4 5 6 7	Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event...(D) Any injury to any client which requires medical treatment.	1 2 3 4 5 6 7	Administrator agreed to submit proof of correction on or before POC due date to CCLD showing completed training certification on reporting requirements from an accredited vendor.
	8 9 10 11 12 13 14	This requirement was not met based on late receipt ot incident report from administrator which posed a potential health & safety risk to client 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: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2021

LIC9099 (FAS) - (06/04)

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