079201047-8-4-2022-15-AS-HHUL-CHNPZ5-20220826114454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201047
Report Date: 08/04/2022
Date Signed: 08/04/2022 04:48:29 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
06/22/2022 and conducted by Evaluator James Sampair

COMPLAINT CONTROL NUMBER: 15-AS-20220622145935

FACILITY NAME:	AGNES HOUSE		FACILITY NUMBER:	079201047
ADMINISTRATOR:	BERNARDINO, ALBERTO		FACILITY TYPE:	740
ADDRESS:	1660 ARKELL RD		TELEPHONE:	(925) 818-6536
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94598
CAPACITY:	6	CENSUS: 3	DATE:	08/04/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Leamae "Mae" Jovellanos		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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1. Lack of care and supervision resulting in wound on resident
2. Staff failed to assist resident with toileting in a timely manner
3. Staff failed to treat resident with dignity.
4. Staff speaking inappropreatly to residents.
5. Facility failed to meet reporting requirements.

INVESTIGATION FINDINGS:

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On 8/4/2022 at 1:30PM, Licensing Program Analyst (LPA) J. Sampair and Licensing Program Manager (LPM) H. Humpal arrived unannounced to conduct a complaint investigation and delivered findings for the allegation above. LPA met with staff member Leamae "Mae" Jovellanos and informed her of the reason for visit. Administrator was notified of the visit by staff.

Over the course of the investigation, LPA interviewed 4 staff and 2 residents and reviewed resident and facility records, including staff logs.

- On 6/5/2022, R1’s private caregiver observed blood on R1’s bedsheet. Based on staff log notes, night staff did not note any bleeding or injuries for R1. S1 stated and provided photos showing that the bleeding was from a scab on R1’s lower leg at the sock level that did not require medical attention and was cleaned once staff became aware. R1 was no longer at the facility. Based on staff interviews and a review of care logs, photos, and videos, there was nothing showing a lack of care and supervision that resulted in the deterioration of the resident's physical condition.

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220622145935

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: AGNES HOUSE	FACILITY NUMBER: 079201047
	VISIT DATE: 08/04/2022

NARRATIVE

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Continued from LIC 9099-C

- R1’s file was reviewed and other resident and staff was interviewed. Based on the information obtained, there is not sufficient information to indicate if staff assisted R1 with his/her toileting needs in a timely manner.

- LPA interviewed total of 3 residents, R2’s private caregiver, and staff in question was interviewed. There were no issues residents raised in regard to staff not treating them with dignity.

- Interviews with current residents did not indicate that they speak inappropriately to residents. Staff denies the allegation.

- LPA reviewed daily staff logs and staff stated, no incident report was generated since it was minor scab to the skin which did not require any medical attention or concern.

Based on the interviews conducted and the records reviewed, the preponderance of evidence standard has not been met, therefore the allegation is found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove it did or did not occur.

Exit interview with staff member Mae Jovellanos was conducted and a copy of this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: James Sampair
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022

LIC9099 (FAS) - (06/04)

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