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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200750
Report Date: 08/09/2024
Date Signed: 08/09/2024 03:20:44 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
12/18/2023 and conducted by Evaluator Luisa Fontanilla
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20231218143948
FACILITY NAME:MERISOL CARE HOMEFACILITY NUMBER:
079200750
ADMINISTRATOR:BACANI, SOLEDADFACILITY TYPE:
740
ADDRESS:4102 PLEIADES PLACETELEPHONE:
(510) 431-3832
CITY:UNION CITYSTATE: CAZIP CODE:
94587
CAPACITY:6CENSUS: 5DATE:
08/09/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Soledad BacaniTIME COMPLETED:
03:50 PM
ALLEGATION(S):
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Staff failed to provide supervision resulting to resident wandering from facility resulting in death
INVESTIGATION FINDINGS:
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On this day at around 2:30 pm, Licensing Program Analyst (LPA) arrived unannounced to deliver
finding on the above allegation. LPA met with Soledad Bacani. LPA explained to Bacani the purpose of the
visit.

During the course of investigation, LPA conducted interviews, gathered copy of R1 death certificate, record reviews, and copy of Union City Police report dated 12/7/2023.

Based on interviews conducted with staff, R1 was confused and had wandering behavior. Staff
interviewed are aware that R1 had Dementia. Staff interviewed confirmed with LPA that R1
would walk around the facility looking for exits, saying, “I want to go home.” Staff are aware
about R1’s elopement incident from a Memory Care unit in another facility prior to placement to
this facility.
continuation on Lic 9099C







Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
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 3
Control Number 15-AS-20231218143948
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: MERISOL CARE HOME
FACILITY NUMBER: 079200750
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/15/2024
Section Cited
CCR
87705(b)(2)
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87705(b)(2) Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Plans of Correction will be addressed in the NCC on 8/15/2024.
Civil penalty determination related to serious bodily injury is pending.
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This requirement is not met as evidenced by:
Based on interviews and record reviews conducted, R1 who has Alzheimer’s/Dementia, confused, disoriented and has sundowning behavior exited the facility without staff knowledge, got struck by a train and died on 12/7/2023.
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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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20231218143948
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: MERISOL CARE HOME
FACILITY NUMBER: 079200750
VISIT DATE: 08/09/2024
NARRATIVE
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On 12/7/2023, R1 eloped from the facility around 0930 hours. A review of Union City Police report indicates that the staff told police R1 possibly exited the facility through dining area sliding
door. The police said that there were sensors on all of the doors that would ring when opened.
However, the sensor was turned off on the sliding door in the dining area, and the backyard
gate was open. R1 was found deceased by the railroad tracks. R1’s date of death as indicated
in the death certificate is listed as “December 7, 2023 unknown hours.” The death certificate
indicates “blunt injuries” as the cause of death, place of injury is “railroad track ballast in Union
City” and description how injury occurred is “pedestrian struck by train.”

R1’s 2023 Physician’s Report (PR) indicates R1 has Alzheimer’s Disease, confused and has
wandering and sundowning behaviors with able to leave facility unassisted listed as “yes.”

However, R1's 2022 Physician's Report (PR) from same treating physician indicates same
diagnosis and behavior with able to leave facility unassisted as “no.” On 5/2/2024, LPA
interviewed R1’s doctor regarding the two PRs. R1’s doctor stated that “….but considering R1
had dementia, R1 should not leave the facility unassisted.”

Based on interviews and record reviews conducted, the preponderance of evidence standard
has been met, therefore the above allegation is found to be substantiated. California Code of
Regulations, Title 22, Sec 87705(b)(2) is being cited on the attached LIC 9099D.

A Non Compliance Conference (NCC) is scheduled for August 15, 2024 to discuss plans of correction.

Civil penalty determination related to serious bodily injury is pending.

A copy of this report was provided to Bacani and Appeal Rights was provided.

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Luisa Fontanilla
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC9099 (FAS) - (06/04)
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