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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200612
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:36:11 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
06/02/2021 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20210602110415
FACILITY NAME:WOODLAND HOMEFACILITY NUMBER:
079200612
ADMINISTRATOR:SALDANA, VICKIFACILITY TYPE:
740
ADDRESS:4219 WOODLAND DRIVETELEPHONE:
(510) 287-8488
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:4CENSUS: 4DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Caroline Koorn, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Neglect/ Lack of supervision resulting in resident sustaining multiple falls resulting in fracture
Facility failed to follow residents care plan
Resident is being financially abused
Staff mishandled a resident's medications while in care
INVESTIGATION FINDINGS:
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On 01/27/2023 starting at 10:45 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the complaint investigation for the above allegations. LPA met with Caroline Koorn, and explained the purpose of the visit.

1. Neglect/ Lack of supervision resulting in resident sustaining multiple falls resulting in fracture
On 06/03/2021, Licensing Program Analyst (LPA) Allison O’Hollaren initiated 10-day investigation and obtained records. Oakland Regional Office made a referral to Investigations Branch (IB) and was accepted as full investigation on 06/03/2021. On 08/01/2022, complaint was reassigned to L. Fontanilla who conducted pre investigation with Reporting Party (RP) on 08/04/2022.

During the course of investigation, the Department obtained records including but not limited to Resident 1 (R1) medical records, death certificate and incident reports and conducted interviews.

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 8
Control Number 15-AS-20210602110415
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: WOODLAND HOME
FACILITY NUMBER: 079200612
VISIT DATE: 01/27/2023
NARRATIVE
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Continued from 9099...
On 05/02/2021, R1 was seen at the John Muir Concord Medical Center for chief complaint of "back pain." R1 was diagnosed with a closed non displaced fracture of the greater trochanter of right femur. Thickening of the right gluteus maximus was noted, which suggested infiltrative hematoma. John Muir Concord Doctor believes the hip fracture and hematoma on the buttock are likely a result of a fall or similar type of trauma to the posterior.

On 05/27/2021, R1 was sent to John Muir Concord Medical Center after an unwitnessed fall in the bedroom. Staff 1 (S1) reported that after R1 was tucked into bed, S1 went to assist another resident. S1 heard a sound in R1’s room. S1 immediately responded and witnessed R1 was slouching on the floor and bleeding from the head. R1 was immediately sent to the hospital. R1 had a head scan which showed acute left subdural hematoma with a 4mm left to right midline shift.

On 05/28/2021, R1 was transferred to John Muir Walnut Creek Medical Center and was admitted to the Intensive Care Unit for a neurosurgery evaluation. Another head scan was conducted, and the subdural hematoma increased to 1.3 cm.

File review documents and staff interviews conclude that R1 was a fall risk resident. R1 was
unsteady while ambulating and sitting down. Fall mats and bed alarms were briefly used but were not successful and as such discontinued. Another fall prevention strategy was reminding R1 to use walker and reminding R1 to sit down. Staff stated that R1 required constant monitoring and supervision. R1 did not have one to one care.

Some of the staff reported that R1 would have benefited from one to one care. S2 stated that R1 was beyond a level of care that the facility could provide based on R1’s need for constant supervision.

R1 passed away prior to being interviewed. Death certificate lists his date of death as 06/05/2021 at 2210 hours. Immediate cause of death is listed as Traumatic Subdural Hematoma. Condition leading to the cause of death/underlying cause is Ground Level Fall.
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 15-AS-20210602110415
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: WOODLAND HOME
FACILITY NUMBER: 079200612
VISIT DATE: 01/27/2023
NARRATIVE
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Continued from 9099C...

Based on interviews and record review, the above allegation is substantiated.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

A Non-Compliance Conference (NCC) will be scheduled.

2. Staff mishandled a resident's medications while in care

During the course of investigation, LPA L. Fontanilla reviewed facility medication list, nursing report and RCEB QA Review. On 3/29/2021, a medication error was recorded by Nursing Manager Ashton Paul when R1’s PRN suppository was not given as prescribed.

A review of R1’s Medication Administration Record (MAR) from March 2021 to May 2021 show that R1’s PRN medicine Bacitracin ointment was not administered throughout the months of March and April 2021. Instructions indicate “apply as needed to open wounds or skin tears until healed.” Bacitracin was administered on May 1, 8, 21 and 26, 2021.

A review of RCEB Home Annual Review indicate there were three (3) medication errors reported for 2020-2021.

Based on record review, the above allegation is substantiated.

3. Resident is being financially abused

On 8/12/2022, LPA L. Fontanilla reviewed an incident report dated 02/16/2021. The report indicates that R1 is missing $100 from P&I money. When staff counted the amount of cash in R1 and other clients’ binder, a significant amount of money was missing from R1’s and all the other clients’ P & I money.

The above allegation is substantiated.

Continued on 9099C...

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 15-AS-20210602110415
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: WOODLAND HOME
FACILITY NUMBER: 079200612
VISIT DATE: 01/27/2023
NARRATIVE
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Continued from 9099C...

4. Facility failed to follow residents care plan

Based on interview conducted with Reporting Party (RP), after R1 was diagnosed with a hip fracture, facility staff and Regional Center of the East Bay (RCEB) staff created a plan that bed alarms would be useful for R1. Facility staff reported that bed alarms and floor mats were implemented for R1’s safety but were unsuccessful and discontinued. Facility staff reported that R1 repeatedly unplugged the bed alarms.

Based on interviews conducted, the above allegation is substantiated.

Exit interview conducted a copy of this report and Appeal Rights was provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 8
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
06/02/2021 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20210602110415

FACILITY NAME:WOODLAND HOMEFACILITY NUMBER:
079200612
ADMINISTRATOR:SALDANA, VICKIFACILITY TYPE:
740
ADDRESS:4219 WOODLAND DRIVETELEPHONE:
(510) 287-8488
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:4CENSUS: 4DATE:
01/27/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Caroline Koorn, AdministratorTIME COMPLETED:
12:50 PM
ALLEGATION(S):
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Facility failed to seek timely medical attention
INVESTIGATION FINDINGS:
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On 01/27/2023 starting at 10:45 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings for the complaint investigation for the above allegation. LPA met with Caroline Koorn, and explained the purpose of the visit.

On 05/02/2021 around “lunch time,” R1 complained of pain in the buttock. Hospital records indicate R1 was seen at the hospital on 05/02/2021 at approximately 11:58 am. Staff reported R1 sustained an unwitnessed fall on 05/27/2021. Staff did not know the exact time of the incident but indicated it was shortly after the start of the night shift (11:00pm). Staff reported paramedics were called quickly after R1 sustained the unwitnessed fall. Medical records indicate the paramedics arrived at the facility approximately 11:36pm.

Based on records reviewed and interviews conducted, the above allegation is unfounded.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
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 8
Control Number 15-AS-20210602110415
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: WOODLAND HOME
FACILITY NUMBER: 079200612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/28/2023
Section Cited
HSC
87468.1(a)(2)
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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
Based on investigation conducted by the Department, Licensee did not comply with the above section...
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A Non-Compliance Conference (NCC) will be scheduled.
An immediate civil penalty of $500 is being assessed for today’s visit.
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 ...R1 was a fall risk and required constant supervision. Facility discontinued using the fall mats and bed alarm. R1 had an unwitnessed fall on 05/27/2021 and died on 06/05/2021. Immediate cause of death is Traumatic Subdural Hematoma and condition leading to the cause of death/underlying cause is Ground Level Fall.
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Deficiency Dismissed
Type A
01/31/2023
Section Cited
CCR
87465(c)(2)
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Once ordered by the physician the medication is given according to the physician's directions.

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Administrator will conduct medication training with staff and submit proof of training to CCL by POC date.
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Based on record review, Licensee did not comply with section above. There were (3) documented medication errors observed in RCEB Home Annual Review for 2020-2021 which poses an immediate threat to health and safety of clients under 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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 15-AS-20210602110415
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: WOODLAND HOME
FACILITY NUMBER: 079200612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2023
Section Cited
CCR
87466
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The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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By POC date, Administrator will review and update the facility’s fall prevention plans for each client and submit a copy to CCL.
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Based on interviews conducted, Licensee failed to comply with section above. Facility staff interviewed state they discontinued the use of alarms and mats due to safety reasons. The plan on use of mats and alarms was created by RCEB and facility staff when R1 was diagnosed with a hip fracture.
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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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 15-AS-20210602110415
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: WOODLAND HOME
FACILITY NUMBER: 079200612
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/03/2023
Section Cited
CCR
80026(e)
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Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash
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By POC date, Licensee will submit to CCL plans on how to ensure clients’ P&I money are intact.
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Based on record review, Licensee did not comply with section above. On 2/16/2021, a large amount of money was missing from R1’s and other clients’ P&I money.
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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: Jill Clancy-Czuleger
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8