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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 397005336
Report Date: 04/07/2021
Date Signed: 04/07/2021 11:39:35 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2021 and conducted by Evaluator Bruce Jacobs
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20210113084547
FACILITY NAME:RM UGALE CARE HOMEFACILITY NUMBER:
397005336
ADMINISTRATOR:MAGSAYO-UGALE, MAYBELYNFACILITY TYPE:
740
ADDRESS:110 E. MT. DIABLO AVENUETELEPHONE:
(209) 836-5215
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 3DATE:
04/07/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maybelyn Ugale, LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bruce Jacobs contacted the facility to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. Telephone call made to this facility and LPA was able to speak with the facility Administrator/Licensee Maybelyn Magsayo-Ugale. This investigation was conducted by the Investigation Branch and consisted of a review of medical records from Sutter Tracy and the facility's records including the Physician’s Report (LIC 602) and care plan. Interviews were conducted with facility management, staff and other witnesses were contacted.

The complaint alleges that facility staff did not seek medical attention in a timely manner. The investigation concluded that the resident (R-1) fell on the way to the bathroom on 11/11/20 at around 4:30 AM. Facility staff did attend to the resident after the fall and provide assistance. However, it was not until 8:00 AM before emergency services were contacted and the resident was sent out to the hospital for evaluation.

As a result of this investigation, the Department has determined the above allegation is (S) Substantiated -

Continued:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2021 and conducted by Evaluator Bruce Jacobs
COMPLAINT CONTROL NUMBER: 27-AS-20210113084547

FACILITY NAME:RM UGALE CARE HOMEFACILITY NUMBER:
397005336
ADMINISTRATOR:MAGSAYO-UGALE, MAYBELYNFACILITY TYPE:
740
ADDRESS:110 E. MT. DIABLO AVENUETELEPHONE:
(209) 836-5215
CITY:TRACYSTATE: CAZIP CODE:
95376
CAPACITY:6CENSUS: 3DATE:
04/07/2021
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Maybelyn Ugale, LicenseeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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9
Resident was hospitalized due to staff neglect.

Staff did not respond to resident's call for assistance in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bruce Jacobs contacted the facility to conclude a complaint investigation via telephone due to COVID-19 and pre-cautionary measures. Telephone call made to this facility and this LPA was able to speak with the facility Administrator/Licensee Maybelyn Magsayo-Ugale. This investigation was conducted by the Investigation Branch and consisted of a review of medical records from Sutter Tracy and the facility's records including the Physician’s Report (LIC 602) and care plan. Interviews were conducted with facility management, staff, residents and other witnesses were contacted.

The complaint alleges that Resident was hospitalized due to staff neglect and staff did not respond to resident's call for assistance in a timely manner. The investigation concluded that the resident (R-1) fell on the way to the bathroom on 11/11/20. Facility staff in the home did attend to the resident after the fall and provide assistance. The resident was subsequently hospitalized for the fall and injury. The resident had no prior history of falls and was not deemed a fall risk at the time. This incident was reported to Licensing.

As a result of this investigation, the Department has determined the above allegations are UNSUBSTANTIATED
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
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 27-AS-20210113084547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336
VISIT DATE: 04/07/2021
NARRATIVE
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A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiency is cited on 9099-D, per Title 22 Regulations, Division 6.

Exit interview conducted and report provided. Appeals rights provided to M. Ugale.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210113084547
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: RM UGALE CARE HOME
FACILITY NUMBER: 397005336
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2021
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the
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Plan of Correction: Facility Administrator will develop a plan and conduct staff training to ensure staff is sufficiently trained on the resident's care and the observation of residents. Also, care staff are properly trained to perform their basic duties to meet the needs of the residents. LPA determined inadequate judgement was used in this situation.
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conditions and needs of residents. This requirement was not met as evidenced by: The resident fell on the way to bathroom on 11/11/20 at 4:30 AM the resident was assisted up and back to bed but emergency services were not contacted and the resident was not sent to the hospital until 8:00 and This poses a potential health and safety risk to the resident.
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 A written Plan of Correction detailing how the facility will implement an adequate procedure to observe and meet the resident's need as well as following the facility's Plan of Operation. POC due by 4/12/21 and completion of training due by 4/30/21.
Type B
04/30/2021
Section Cited
CCR
87208(a)1)
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Plan of Operation (a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. The plan and related materials shall contain the following:(1) Statement of purposes and program goals.
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Plan of Correction: Facility Administrator will develop a plan and conduct staff training to ensure staff is sufficiently trained on the resident's care and the observation of residents. Also, care staff are properly trained to perform their basic duties to meet the needs of the residents. LPA determined inadequate judgement was used in this situation.
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This requirement was not met as evidenced by: The facility's Plan of Operation specifies that residents be medically evaluated after a fall and resident (R-1) was not sent out until the responsible party called for emergency services. This posed a potential safety issue for clients in care.
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 A written Plan of Correction detailing how the facility will implement an adequate procedure to observe and meet the resident's need as well as following the facility's Plan of Operation. POC due by 4/12/21 and completion of training due by 4/30/21.
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: Liza King
LICENSING EVALUATOR NAME: Bruce Jacobs
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4