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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 015600740
Report Date: 09/21/2022
Date Signed: 09/21/2022 11:42:58 AM

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
05/17/2022 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220517085029
FACILITY NAME:A NEW HAVEN CARE HOMEFACILITY NUMBER:
015600740
ADMINISTRATOR:ROBERT ABELLAFACILITY TYPE:
740
ADDRESS:949 DOLORES STREETTELEPHONE:
(925) 784-3842
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:6CENSUS: 5DATE:
09/21/2022
ANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Arnold Soleta, Licensee
Roberto Abella, Administrator		TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Resident sustained a stage 4 pressure injury while in care.
INVESTIGATION FINDINGS:
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On 9/21/2022 at 9:58AM, Licensing Program Analysts (LPAs) G. Luk and M. Malik arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with caregiver, Jesusimo Tolentino and explained to him the reason for the visit. Administrator, Roberto Abella arrived 20 minutes later. Licensee, Arnold Soleta arrived an hour later.

During the course of the investigation, the Department conducted interviews with staff, residents, witnesses, and complainant. Resident’s physician’s report, care plan, care notes, email correspondence, photographs of wound, and hospice records were obtained and reviewed.

(Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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 3
Control Number 15-AS-20220517085029
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: A NEW HAVEN CARE HOME
FACILITY NUMBER: 015600740
VISIT DATE: 09/21/2022
NARRATIVE
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Record review showed staff did not change R1’s diaper or reposition R1 overnight. Interview with staff indicated that staff conduct diaper changes every 2-3 hours. However, staff stated that R1 was heavy to lift and would yell when staff tried to reposition R1. On hospice’s initial visit on 3/12/2022, R1 was found wearing two diapers and laying on top of chux pads. R1’s wound was already at a stage 4 when hospice began treating R1. W3 stated that a wound can develop from a stage 1 to a stage 4 within a couple hours if the resident is not repositioned, remains in the same position for hours, and their diapers are not changed.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. Health and Safety Code, are being cited on the attached LIC9099D.

A $500.00 immediate civil penalty is being assessed on this day. Civil penalty determination related to serious bodily injury is pending. A formal conference with CCLD will be schedule at a later time.

Exit interview conducted with Arnold. A copy of this report, civil penalty, and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20220517085029
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: A NEW HAVEN CARE HOME
FACILITY NUMBER: 015600740
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/22/2022
Section Cited
HSC
1569.269(a)(10)
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Enumerated rights; severability. To be free from neglect,...humiliation, intimidation, and verbal, mental, physical, or sexual abuse.
This requirement is not met as evidience by:
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Administrator has agreed to re-train all staff regarding care of residents with pressure injuries in various stages and submit training materials & staff sign in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above resulting in R1 sustaining a stage 4 pressure injury which poses an immediate health and safety risk to the persons in care.
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A formal conference with CCLD will be schedule at a later time.

$500.00 immediate civil penalty is assessed.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3