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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600130
Report Date: 11/20/2020
Date Signed: 11/20/2020 11:24:11 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:TIFFANY GARDENSFACILITY NUMBER:
015600130
ADMINISTRATOR:ERIC STAMMFACILITY TYPE:
740
ADDRESS:790 HOLMES STREETTELEPHONE:
(925) 371-3090
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:31CENSUS: 22DATE:
11/20/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Anelli Stamm, Licensee
Frederick Stamm, Licensee
Cherry Marcelo, Former Administrator
TIME COMPLETED:
11:00 AM
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An office meeting was held on November 20, 2020 to follow up on substantiated allegations of Neglect/Lack of Supervision. Present at the conference were Harpreet Humpal, Licensing Program Manager, Grace Luk, Licensing Program Analyst, Anelli Stamm, Licensee, Frederick Stamm, Licensee, and Cherry Marcelo, Former Administrator.

On May 25, 2017, the Department concluded a complaint investigation and substantiated allegations that as the result of neglect, a resident (R1) sustained multiple pressure injuries, including an unstageable pressure injury to R1’s left heel, two stage 2 pressure injuries to R1’s right ankle; and a stage 2 coccyx pressure injury. It was also determined that facility staff failed to obtain timely medical treatment when there was a change in condition to the wound on R1’s left heel, and when R1 was found unresponsive on December 6, 2016.

The licensee was cited for violating California Code of Regulations (CCR) Title 22, §87466 Observation of the Resident after R1 sustained an unstageable pressure injury and stage 2 pressure injuries as the result of negligence and not getting timely medical attention. The licensee was further cited under CCR Title 22, § 87465(a)(1) Incidental Medical and Dental Care. An x-ray was ordered by R1’s Primary Care Physician (PCP) on November 23, 2016 and the license failed to make arrangements to get this completed and R1 ended up going to the Emergency Room (ER) at a general acute care hospital. The licensee was also cited under CCR Title 22, § 87465(g) Incidental Medical and Dental Care after R1 was found unresponsive by staff on December 6, 2016 and staff failed to immediately call 9-1-1.
(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TIFFANY GARDENS
FACILITY NUMBER: 015600130
VISIT DATE: 11/20/2020
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R1 was admitted to the facility on October 3, 2016 from Post-Acute Care Center (hospital). According to R1’s spouse, prior to admission R1 was able to walk by using a walker. According to R1’s Physician Report, dated September 29, 2016, there was no history of skin condition or breakdown. Home health agency made 6 visits between October 5, 2016 and November 12, 2016. There was no mention on their notes of any wound during this period. Specifically, on November 2, 2016 and on November 15, 2016, the notes indicate that there was a skin assessment. Skin was intact and no pressure ulcers were noticed.

The investigation revealed that on November 22, 2016, according to the Facility’s Daily Shift Note, a pressure injury was observed on R1’s ankle and an x-ray was ordered by R1’s PCP on November 23, 2016. The facility staff attempted to schedule an x-ray, however the facility staff was not successful and failed to follow-up on scheduling the x-ray. Based on the caregiver statements and medical records, the condition of R1’s ankle changed between November 22, 2016 and November 26, 2016, and facility staff did not seek further medical attention. On November 26, 2016, R1 was sent to the ER for treatment. At that time, the heel wound was determined to be an unstageable, suspected deep tissue injury measuring at 6.8 cm with unknown depth, ruptured blood blister with maroon purple wound bed. According to the National Pressure Ulcer Advisory Panel (NPUAP), unstageable pressure injury is defined as full thickness tissue loss in which the bade of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and /or eschar (tan, brown or black) in the wound bed. It was also determined that R1 had two stage 2 pressure injuries on R1’s right ankle (2.5 x 2.5 cm). NPUAP defines stage 2 pressure injury as partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister (https://npiap.com/page/PressureInjuryStages).

Facility Daily Shift Note dated November 24, 2016 (p.m. shift) also indicated a sore on the back was observed. However, there is no record of reporting the sore on the back to R1’s family or PCP. This sore later developed to a stage 2 coccyx wound (8 x 2.5 x 0.2 cm). There were no notes in ER records for the November 26, 2016 visit mentioning the “sore on the back.” R1 was discharged back to the facility on the same day with an order for Home Health Agency (HHA) to provide wound care for the bilateral ankles. On November 28, 2016, December 2, 2016, and December 5, 2016, HHA visited R1 and instructed facility staff to apply barrier cream to the coccyx area.

(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: TIFFANY GARDENS
FACILITY NUMBER: 015600130
VISIT DATE: 11/20/2020
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On December 6, 2016, R1 was found unresponsive by caregivers; the caregivers then reported this to the charge caregiver. The charge caregiver then assessed R1. The charge caregiver then called R1’s spouse, who responded to the facility. Upon the spouse’s arrival, the spouse asked the facility staff to call 9-1-1, and R1 was sent to the ER. R1 was diagnosed as follows: altered level of consciousness, possibly secondary to cellulitis infection, worsening dementia, sepsis without acute organ dysfunction; and Stage 2 pressure injury of the coccyx. According to the Mayo Clinic, “sepsis is a potentially life-threatening condition caused by the body's response to an infection. The body normally releases chemicals into the bloodstream to fight an infection. Sepsis occurs when the body's response to these chemicals is out of balance, triggering changes that can damage multiple organ systems.” R1 was treated and discharged on December 14, 2016 to a skilled nursing facility with home health wound care.

Based on observation, interviews, record review, and the department findings, the licensee failed to obtain timely medical attention for R1. This caused R1 to suffer a serious bodily injury requiring hospitalization and sustaining unstageable and three stage 2 pressure injuries (one on coccyx and two on the right ankle).

At the time of the complaint visit on May 25, 2017, an immediate civil penalty of $150 was issued. The licensee was informed that an additional civil penalty is still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code § 15610.67 defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

Today, November 20, 2020 the Department is issuing a civil penalty per Health and Safety Code § 1569.49 in the amount of $10,000 for a violation that the Department constitutes as serious bodily injury. However, since an immediate civil penalty of $150 was previously issued on May 25, 2017 the amount of the civil penalty issued today is reduced to $9,850. A copy of the LIC 421D was given to the facility representative and original signatures are in the facility file.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. Licensee signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020
LIC809 (FAS) - (06/04)
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