015600812-9-11-2024-15-AS-BFOG-DCJNRL-20250102094140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 015600812
Report Date: 09/11/2024
Date Signed: 09/11/2024 01:46:07 PM

Unsubstantiated

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
01/17/2024 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20240117174057

FACILITY NAME:	ANDRE ALEXIS GUEST HOME		FACILITY NUMBER:	015600812
ADMINISTRATOR:	JUNTILLA, ALEX P.		FACILITY TYPE:	740
ADDRESS:	1617 CHARLES ROAD		TELEPHONE:	(510) 430-1351
CITY:	SAN LEANDRO	STATE: CA	ZIP CODE:	94577
CAPACITY:	6	CENSUS: 5	DATE:	09/11/2024
		UNANNOUNCED	TIME BEGAN:	01:34 PM
MET WITH:	Alex Juntilla, Administrator		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Resident developed multiple pressure wounds while in care
Resident in care sustained unexplained bruising
Facility staff do not allow resident to have visitors
Facility staff left residents in soiled clothing

INVESTIGATION FINDINGS:

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On 09/10/24 at 1:34PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with administrator (ADM) to deliver findings of above allegations. LPA explained the purpose of the visit with ADM.

During investigation, the department obtained the following documents from administrator – personnel record, residents’ roster, resident appraisal, admission agreement, physicians reports, hospital after visit summaries, incident reports visitors’ logs.

Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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-20240117174057

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: ANDRE ALEXIS GUEST HOME	FACILITY NUMBER: 015600812
	VISIT DATE: 09/11/2024

NARRATIVE

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Allegation: Resident developed multiple pressure wounds while in care
Finding: Unsubstantiated
During investigation, LPA reviewed resident’s (R1) admission agreement which showed R1 was first admitted at the facility on 09/24/23 with existing pressure injuries on his left buttock, R1’s hospital after visit summaries dated 10/2023 until 01/17/24 showed the home health care team and staff provided care and supervision in decreasing R1’s risk of recurrence of pressure injuries. Medical records also showed R1 was visited and treated by the home health care team several times (10/23/23 until 12/26/23) for pressure injuries and instructed staff on interventions to prevent pressure injuries using home care patient education guide. On 12/26/23, Home Health records indicate that R1 was discharged as No Further Home Health needed. Home Health records were reviewed and notes from the nurse did not indicate there were any concerns with facility staff providing the care needed for R1. Staff (ADM, S1) confirmed with LPA that they followed home health’s pressure injury instructions and ordered air mattress/cushions to aid in preventing pressure injuries. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that the resident developed multiple pressure wounds while in care and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Continued on next page, LIC 9099-C pg1

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20240117174057

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: ANDRE ALEXIS GUEST HOME	FACILITY NUMBER: 015600812
	VISIT DATE: 09/11/2024

NARRATIVE

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Allegation: Resident in care sustained unexplained bruising
Finding: Unsubstantiated
During investigation, staff (ADM, S1) stated resident (R1) has become increasingly aggressive towards staff when cleaning and giving him a shower. Review of incident reports dated 12/31/23 and 01/08/24 showed R1 wildly swung his arms, kicked staff while changing him in the bathroom and spat on their faces. Staff (ADM, S1) stated R1’s violent behaviors required 2 staff to assist him with his activities of daily living (ADLs) and that R1’s responsible party has been notified that R1 needs a higher level of care. The LPA observed that the Home Health Records do not indicate a concern for unexplained bruising or injuries; and during the subject time period, documented that R1 was a fall risk. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that resident in care sustained unexplained bruising and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Allegation: Facility staff do not allow resident to have visitors
Finding: Unsubstantiated
During investigation, staff denied that resident (R1) is not allowed to have visitors at the facility. Review of facility’s visitors’ logs dated 10/23/23 until 01/12/24 showed R1 was visited at the facility by home health therapists 2 to 3 times per week (10/23/23, 10/25/23, 10/30/23, 11/01/23, 11/03/23, 11/13/23, 11/16/23, 12/09/23, 12/11/23) and family members/friend (12/15/23, 12/21/23, 12/24/23, 12/26/23, 01/03/24, 01/11/24). Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that facility staff do not allow the resident to have visitors and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.
Continued on next page, LIC 9099-C pg2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20240117174057

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: ANDRE ALEXIS GUEST HOME	FACILITY NUMBER: 015600812
	VISIT DATE: 09/11/2024

NARRATIVE

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Allegation: Staff left residents in soiled clothing
Finding: Unsubstantiated
During investigation, LPA observed residents (R1, R2, R3) clean and odor free (no urine or feces smells) during visit on 01/18/24. Staff (ADM. S1) denied leaving any resident in soiled clothing. Staff stated they check and monitor residents every 2 hours and change their diapers as needed. Review of R1’s home health records dated 12/09/23 showed wound care was provided by home health nurse/care team and staff 2 times per week to R1’s buttocks pressure injuries with diaper changes every 2 hours. The LPA observed that the Home Health records do not indicate a concern for neglect pertaining to incontinence care. Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff left residents in soiled clothing and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC9099 (FAS) - (06/04)

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