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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 355202348
Report Date: 05/09/2022
Date Signed: 05/11/2022 12:07:06 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,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210908082921
FACILITY NAME:CLEARVIEW CAREHOMES,INC.FACILITY NUMBER:
355202348
ADMINISTRATOR:FELICIDAD RAMOS KANKELBORGFACILITY TYPE:
740
ADDRESS:3370 CIENEGA ROADTELEPHONE:
(831) 637-4463
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:6CENSUS: 4DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:F. KankelborgTIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Staff did not provide resident assistance with incontinence care
Licensee did not administer resident's medications as prescribed by physician
Licensee did not maintain a record of doses of medications
Licensee did not inform responsible party of resident's change in condition
Facility does not serve residents balanced meals
INVESTIGATION FINDINGS:
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LPA Johnson arrived unannounced to deliver findings for the above complaint allegation.

Allegation: Staff did not provide resident assistance with incontinence care.

Based on records reviewed the facility provided to R1's insurance agency a complete list of activities of daily living (ADLS), as part of this information provided to the insurance agency incontinence care was part of the daily routine for R1's care from 4/2021 until 8/2021. This is documented information that was obtained by the department as part of the investigation. LPA was unable to collaborate the reported information.

Allegation: Licensee did not administer resident's medications as prescribed by physician

Continued***
Unsubstantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
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 26-AS-20210908082921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: CLEARVIEW CAREHOMES,INC.
FACILITY NUMBER: 355202348
VISIT DATE: 05/09/2022
NARRATIVE
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The department was able to review a list of medication as part of R1's care plan from the hospice agency. The medication records were written on on-going notes provided by the hospice agency and on the centrally stored log of medication for each medication that came into the facility. These records confirmed that R1's medication were sent to the facility and the notes support that the medications were given as needed per the doctors orders. The facility did not use a Medication Administration Record (MAR) to track the daily use of the medication given. LPA could not determine if medication were missed or not given as reported.

Allegation: Licensee did not maintain a record of doses of medications

The records reviewed indicated that the facility was using a form of documentation to track the controlled medications given including Morphine and Ativan. The documentation was written on a Nurse's Medication Notes. The other medications given were not documented on a MAR. LPA was able to determine that some medications were given but could not establish that all were given based on reported information and records reviewed.

Allegation: Licensee did not inform responsible party of resident's change in condition.

Based on records reviewed the facility provided R1 with the care addressed in the hospice services plan. R1 was on hospice when discharged to the facility and may have had a change in conditions that was a normal process in the expected outcome for R1's prognosis as a hospice patient. When R1 moved out of the facility the excepting facility did not assess R1 at his then current facility prior to R1 moving out. R1 moved out without notice to the facility.

Allegation: Facility does not serve residents balanced meals.

Based on records reviewed and interviews with 2 of 4 residents in care the facility according to those interviewed confirmed that the facility provides the residents with good meals. LPA was unable to determine if R1 was receiving balanced meals at the time of the complaint. LPA was able to review a menu used as a sample for the time period that covered the reported complaint timeline.

The department has investigated the above allegations and finds the allegation to be UNSUBSTANTIATED. A finding that a complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation did or did not occur, therefore the allegation is unsubstantiated.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/08/2021 and conducted by Evaluator Albert Johnson
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20210908082921

FACILITY NAME:CLEARVIEW CAREHOMES,INC.FACILITY NUMBER:
355202348
ADMINISTRATOR:FELICIDAD RAMOS KANKELBORGFACILITY TYPE:
740
ADDRESS:3370 CIENEGA ROADTELEPHONE:
(831) 637-4463
CITY:HOLLISTERSTATE: CAZIP CODE:
95023
CAPACITY:6CENSUS: 4DATE:
05/09/2022
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:F. KankelborgTIME COMPLETED:
03:58 PM
ALLEGATION(S):
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Resident sustained injury while in care
INVESTIGATION FINDINGS:
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Based on interview with the Licensee, the department was able to determine that R1 had sustained a superficial injuries while in care as a result of laying on the floor or banging his hand on the bed post. The facility did not have any records of R1 going out to the facility as a result of a fall. R1 was assessed on 4/13/2021 as a high risk for falls and skin breakdown. The facility had a service plan to address those needs.

As a result of this investigation, this LPA found the allegation to be SUBSTANTIATED - A finding that the complaint was Substantiated meant that the allegation was valid because the preponderance of the evidence standard had been met.
The following deficiencies were cited on the following LIC 9099-D pursuant to Title 22 Rules and Regulations, Division 6 and Health and Safety Codes.

Appeal rights were given and a copy was left with the facility at this time. Exit Interview

Substantiated
Estimated Days of Completion: 0
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20210908082921
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CLEARVIEW CAREHOMES,INC.
FACILITY NUMBER: 355202348
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2022
Section Cited
CCR
87464(f)(1)
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Basic Services. Basic services shall at a minimum include: Care and supervision.
This requirement is not met as evidenced by
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Licensee and LPA agree to: Submit a plan on how the facility will ensure that residents are provided with a plan to address self injurious behavior. the plan will be submitted by POC due date 5/20/2022.
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Based on interview with the Licensee, the department was able to determine that R1 had sustained superficial injuries while in care as a result of laying on the floor or banging his hand on the bed post. . This poses a potential health and safety risk to residents 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: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4