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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201195
Report Date: 02/27/2025
Date Signed: 06/13/2025 02:11:24 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
01/31/2025 and conducted by Evaluator Gregory Clark
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20250131140127
FACILITY NAME:SCARLET HOUSE FOR THE ELDERLYFACILITY NUMBER:
079201195
ADMINISTRATOR:WHITE, RACHELFACILITY TYPE:
740
ADDRESS:5111 PAUL SCARLET DRIVETELEPHONE:
(650) 580-3239
CITY:CONCORDSTATE: CAZIP CODE:
94521
CAPACITY:6CENSUS: 2DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Ace White, LicenseeTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff improperly transferred resident resulting in resident sustaining multiple fractures while in care
INVESTIGATION FINDINGS:
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On 6/13/25 LPA arrived to deliver amened report. On 2/27/25 at 10:30 a.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct an initial 10-day complaint investigationand deliver findings in regard to the allegation above. LPA met with Ace White, Licensee and explained the purpose of the visit. At 2:00 p.m. Ace White had to leave and gave permission for care staff Jose Coronel to sign the reports.

During the course of the investigation LPA interviewed W1 and facility staff. LPA also reviewed documents related to R1.

R1 was admitted to the facility on 3/4/23 and moved out on 1/30/25. R1 is non-ambulatory. R1's needs and services plan indicate that she needs a 2 -3 person assist for transfers and was identified as a fall risk.

***report contine on LIC9099C***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
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-20250131140127
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: SCARLET HOUSE FOR THE ELDERLY
FACILITY NUMBER: 079201195
VISIT DATE: 02/27/2025
NARRATIVE
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***report continues fron LIC9099***


On December 5, 2024, at around 11:00 a.m. S2 and S3 were assisting R1 into the shower stall in a shower chair when R1’s leg got caught between the shower chair and shower wall after which R1 started complaining of pain in her leg. Facility staff were all instructed to call R1’s Responsible Party (RP) before seeking any medical attention for R1. S2 called R1’s RP who advised staff to call 911. R1 was taken to Kaiser Walnut Creek and diagnosed with a fractured right tibia.

Interviews with S2 and S3 confirmed that the injury was an accident and that they never had any trouble moving R1 into the shower prior that incident.

Review of medical records from Kaiser Walnut Creek indicate that R1 did sustain a fracture of her right tibia.

Based on LPA document review and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

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


Exit interview conducted, a copy of this report and appeal rights provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20250131140127
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: SCARLET HOUSE FOR THE ELDERLY
FACILITY NUMBER: 079201195
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/27/2025
Section Cited
CCR
87464(f)(1)(c)
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87464 Basic Services (f)Basic services shall at a minimum include: (1)Care and supervision…. (c) "Care and supervision" means the facility assumes responsibility for...assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered.
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Administrator to re-train staff in the proper way to transport R1 into her shower chair and into the shower and send proff to CCL by POC date.

POC cleared during visit.

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This requirement is not met as evidenced by: Based on observation the licensee did not comply with the section cited above. Staff injured a resident while assisting her into the shower which poses an immediate health, safety, or personal rights risk to 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: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3