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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201134
Report Date: 09/06/2024
Date Signed: 09/06/2024 02:52:47 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
02/12/2024 and conducted by Evaluator Laura Hall
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20240212113726
FACILITY NAME:ANGEL CARE HOMEFACILITY NUMBER:
079201134
ADMINISTRATOR:WANG, DINGFACILITY TYPE:
740
ADDRESS:1723 LIMEWOOD PLACETELEPHONE:
(925) 635-3936
CITY:PITTSBURGSTATE: CAZIP CODE:
94553
CAPACITY:6CENSUS: 5DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Wilfredo Bacani, CaregiverTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Staff did not prevent a resident from sustaining a pressure injury while in care

Staff did not apprise the resident's family of the resident's pressure injury while in care.
INVESTIGATION FINDINGS:
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On 9/6/2024 at 1:20pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Wilfredo Bacani, Caregiver, and explained the purpose of the visit. LPA spoke with Administrator, Ding Wang, via telephone.

The Department concluded a complaint investigation and substantiated the following two (2) allegations: staff did not prevent a resident from sustaining a pressure injury while in care, and staff did not apprise the resident’s family of the resident’s pressure injury while in care.

Based on the investigation, it was revealed that staff neglect resulted in R1 developing pressure injuries.

Continued on LIC9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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-20240212113726
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: ANGEL CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 09/06/2024
NARRATIVE
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During the investigation the Department interviewed the reporting party (RP), staff, a witness (W1), obtained and reviewed R1’s medical records from Contra Costa Regional Medical Center.

R1 was admitted to this facility from Contra Costa Regional Medical Center (CCRMC) on 10/6/2023. R1’s discharge diagnosis was major neurocognitive disorder, due to vascular disease, with mild behavioral disturbance. No pressure injuries were noted but the plan of care notes dated 10/6/2023, listed R1 as “at risk for skin impairment”.

Interviews and Contra Costa Regional Medical Center records indicated that on 1/2/2024, R1 was admitted to CCRMC with a chief complaint of a wound check. R1 was assessed and was diagnosed with a stage four pressure injury on his right hip, an unstageable pressure injury on his left buttocks, a stage one pressure injury on his right knee, and a deep tissue pressure injury on his left hip and left heel.

On 6/4/2024, interviews with facility staff (S2 and S3) stated, R1 had one pressure injury on his buttocks /coccyx area. S2 described it as a “small wound, that was kind of open”. S2 added that she reported this to the administrator (S1) when she saw the wound and that wound “needs treatment”.

S1 was interviewed and she made inconsistent statements about what happened with R1. S1 initially stated she only saw one pressure injury on R1’s right hip, but during a follow-up interview admitted to seeing the other pressure injuries. S1 did not consider the “wounds” as pressure injuries because they were not “open” but referred as “black spots bruises”.

Based on the investigation, staff did not apprise the resident’s family of the resident’s pressure injury while in care.

Continued on LIC9099C.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 15-AS-20240212113726
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: ANGEL CARE HOME
FACILITY NUMBER: 079201134
VISIT DATE: 09/06/2024
NARRATIVE
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Continued from LIC9099C.

During interview with W1 on 03/27/2024, it was stated that she was not aware that R1 had any pressure injuries. W1 was notified by the hospital that R1 was admitted. Furthermore, the facility did not furnish to the licensing department a report of a serious injury as determined by the attending physician and occurring while the resident was under facility supervision. This will be addressed separately on a case management visit.


Deficiencies are cited under the California Code of Regulations, Title 22, Division 6, follows on LIC9099D.

*A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to injury of client is pending. *

Exit interview conducted. A copy of the appeal rights, LIC421M, and this report provided.

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 15-AS-20240212113726
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: ANGEL CARE HOME
FACILITY NUMBER: 079201134
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2024
Section Cited
CCR
87468.2(a)(4)
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87468.2 (a) In addition to the rights listed in Section 87468.1... residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (2) To have their records and personal information remain confidential and to approve their release, except as authorized by law.
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Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later.
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This requirement was not as evidence by:
Based on interview and record review the Licensee did not comply with the section cited above in preventing resident from having pressure injury, which poses an immediate health and safety risk to persons in care.
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*A civil penalty of $500.00 was assessed on today's date.
Type A
09/07/2024
Section Cited
CCR
87466
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87466 Observation of the Resident
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. When changes... or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met as evidence by:
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Licensee agrees to attend the mandatory noncompliance conference (NCC). Date to be sent later.
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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: Laura Hall
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4