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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200484
Report Date: 09/30/2024
Date Signed: 09/30/2024 04:06:34 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
06/30/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230630123752
FACILITY NAME:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 37DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Harmony Venturelli, Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not providing resident's authorized representative with resident's incident documents
INVESTIGATION FINDINGS:
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On 9/30/2024 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegation above. LPA met with Executive Director, Harmony Venturelli and explained the purpose the visit.

During the course of the investigation, the Department and LPA G. Luk conducted interviews with staff, residents, witnesses, and complainant. Staff schedule, physician's report, care plan, emergency information, care notes, incident reports, medical records, hospice records, and death certificate were obtained and reviewed.

Interview with staff revealed that when documents are sent to family, it would be noted in the care notes. R1's care notes revealed that R1's family had requested information on R1's incident that occurred on 4/18/2023. However, interviewed witness revealed that R1's family did not receive requested reports for R1's incident. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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 5
Control Number 15-AS-20230630123752
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: SUNOL CREEK MEMORY CARE
FACILITY NUMBER: 019200484
VISIT DATE: 09/30/2024
NARRATIVE
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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 with Harmony Venturelli. A copy of this report and appeal rights provided.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230630123752
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: SUNOL CREEK MEMORY CARE
FACILITY NUMBER: 019200484
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/18/2024
Section Cited
CCR
87211(a)(1)
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Reporting Requirements. A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events...This requirement is not met as evidence by:
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Executive Director (ED) has agreed to review reporting requirements and conduct training for staff regarding reporting requirements. ED will submit 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 by not providing a written report to the family which poses a potential health and safety risk to the persons in care.
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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: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/30/2023 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230630123752

FACILITY NAME:SUNOL CREEK MEMORY CAREFACILITY NUMBER:
019200484
ADMINISTRATOR:ROSE, JESSICAFACILITY TYPE:
740
ADDRESS:5980 SUNOL BLVDTELEPHONE:
(925) 846-8283
CITY:PLEASANTONSTATE: CAZIP CODE:
94566
CAPACITY:46CENSUS: 37DATE:
09/30/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Harmony Venturelli, Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Questionable death
Resident sustained severe injuries due to staff neglect
Staff handled residents in a rough manner
INVESTIGATION FINDINGS:
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On 9/30/2024 at 11:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to deliver complaint findings for the allegations above. LPA met with Executive Director, Harmony Venturelli and explained the purpose the visit.

During the course of the investigation, the Department and LPA G. Luk conducted interviews with staff, residents, witnesses, and complainant. Staff schedule, physician's report, care plan, emergency information, care notes, incident reports, medical records, hospice records, and death certificate were obtained and reviewed.

Questionable Death
Incident report revealed that on 4/18/2023 R1 was observed leaning forward in the wheelchair and fell forward out of the wheelchair on right side onto the floor. (Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230630123752
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: SUNOL CREEK MEMORY CARE
FACILITY NUMBER: 019200484
VISIT DATE: 09/30/2024
NARRATIVE
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R1 was evaluated by facility nurse and R1 was alert and responsive, able to display range of motion in all extremities, able to stand and bear weight with assistance, but complained of mild right shoulder pain. Hospital records revealed that R1 was found to have a fracture on right proximal humerus. R1 was medically cleared to return to the facility after a couple days at the hospital. On 4/30/2023, R1 was sent out to the hospital due to shortness of breath. Medical records revealed that R1’s tongue rolled up which obstructed airway. The CT exam showed no signs of intracranial hemorrhage. R1 returned to the facility with hospice services on 5/1/2023. Hospice records revealed that R1 had regular difficulty swallowing medication and food which lead to a decline in health. R1’s death certificate indicated the cause of death was vascular dementia.

Resident sustained severe injuries due to staff neglect
Interview with staff indicated that R1’s fall was an accident and R1 have not fallen off the wheelchair before. S2 stated R1 was known to lean forward and to prevent R1 from falling off the wheelchair, staff would place pillows on R1’s side. When S2 was taking R1 to the room to change diaper, R1 leaned forward and fell off the wheelchair into her right side. S2 was unsure how R1 fell because R1 had pillows on her sides. Facility staff have conducted training on dementia care, alternatives to restraints in elder care, proper positioning, safe transfers, and falls in assisted living.

Staff handled residents in a rough manner
Interview with staff revealed that they have not witness staff being rough with residents. Interview with resident indicated that staff are very nice and polite people.

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.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Grace Luk
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5