<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200807
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:18:28 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
05/22/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230522092645
FACILITY NAME:CONTINUANCE CARE HOME LLCFACILITY NUMBER:
019200807
ADMINISTRATOR:MARSHALL, SHIRLEYFACILITY TYPE:
740
ADDRESS:565 SCHAFER RDTELEPHONE:
(510) 398-8994
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:16CENSUS: 15DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mandar Kulkarni TIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident developed multiple pressure injuries due to neglect by staff
Facility staff did not seek timely medical attention for residents pressure injuries
Facility administrator is not present in the facility due to illness.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On November 29 2023 at 9:15 am, Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegations. LPA met with Staff member Wyrek Fagin and explained the reason for the visit. Administrator Sherley Marshall was called to be informed but was unable to come to the facility and Licensee Mandar Kulkarni was called and joined later.

The Department’s investigation included but was not limited to interviews with staff, residents, and the reporting party. The Department obtained copies of Resident’s (R1) medical records, Physician’s Report, Pre-placement Appraisal, Appraisal/Needs and Services Plan, list of medications, Facility Notes, Unusual Incident Reports, and staff training.

Allegations: Resident developed multiple pressure injuries due to neglect by staff and facility staff did not seek timely medical attention for resident’s pressure injuries.

Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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 5
Control Number 15-AS-20230522092645
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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807
VISIT DATE: 11/29/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
...Continued from LIC 9099
R1 was admitted to this facility in October 2021. On May 18, 2023, R1 was brought to the hospital after the family was notified by licensee that R1 had pressure injuries. R1 was diagnosed with an unstageable pressure injury to his hip, a stage three pressure injury to his left heel and a stage four pressure injury to his right heel. Staff (S1) reported she was caring for the wounds by copying what she had seen other Home Health nurses do. S1 reported she has never received formal training on how to care for wounds and never notified the family of the progressing wounds or sought medical attention. S1 believed the wounds were a result of R1 not being able to move and because he would “stay in one spot all the time”. Administrator, Shirley Marshall, never notified the family or sought medical attention, stating the wounds “got away from me”.

Based on interviews and records review, S1 stated she would not seek medical attention or notify the family, regardless of how bad the wound was, as that was administrator’s responsibility. Facility administrator acknowledged R1 was not receiving appropriate care for his progressing wounds. Staff interviewed confirmed no medical attention was sought prior to May 15, 2023.

Allegation: Facility administrator is not present in the facility due to illness



Based on interviews, records review and observations, licensee did not comply with the above regulations. Facility administrator, Shirley Marshall, has not been involved in her daily administrative duties at least since March 2023. Ms. Marshall as confirmed this is due to her own ongoing medical issues and/or chronic illness, requiring treatments and routine medical appointments. Staff and family members of the residents have observed the absence of the administrator.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC 9099D. A $500.00 immediate civil penalty is assessed today, Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1569.49(f).
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20230522092645
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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
HSC
1569.269(a)(10)
1
2
3
4
5
6
7
To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement is not met as evidence by: Based on the investigation, the licensee
1
2
3
4
5
6
7
Correction: A formal conference with CCLD will be scheduled at a later time. A $500.00 immediate civil penalty is assessed on this day. Licensee was informed that an additional civil penalty is still being determined based on Health & Safety Code 1569.49(f)
8
9
10
11
12
13
14
 failed to comply with the section code cited above. This resulted in R1 developing an unstageable pressure injury to his hip, a stage 3 pressure injury to his left heel, and stage 4 pressure injury to his right heel. This posed an immediate health and safety risks to resident in care.
8
9
10
11
12
13
14
Type A
12/01/2023
Section Cited
CCR
87464(f)(5)(6)
1
2
3
4
5
6
7
Basic services shall at a minimum include Regular observation of the resident's physical and mental condition, as specified in Section 87466, Observation of the Resident. Arrangements to meet health needs,... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
mandatory meeting will be held at a later date.
8
9
10
11
12
13
14
Based on interviews and records review, this requirement was not met as evidenced by staff members stating that they were not responsible for seeking medical attention for the residents and they were to inform the administrator.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
05/22/2023 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20230522092645

FACILITY NAME:CONTINUANCE CARE HOME LLCFACILITY NUMBER:
019200807
ADMINISTRATOR:MARSHALL, SHIRLEYFACILITY TYPE:
740
ADDRESS:565 SCHAFER RDTELEPHONE:
(510) 398-8994
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY:16CENSUS: 15DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH: Wyrek Fagin, Staff MemberTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff are not repositioning resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On November 29th 2023 at 9:15 am Licensing Program Analyst (LPA) J. Clancy-Czuleger arrived unannounced to deliver findings on the above allegations.

Based on the investigation, above allegation will be deemed Unsubstantiated. The licensee failed to seek timely medical attention for R1 and a care plan was not developed for R1 to address the issues of repositioning. Staff interviewed did not follow any specific guidelines to address the severity of the pressure injuries. S3 stated R1 refused to move and “would stay in one spot all the time.”

A finding that the 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 occurred.

Exit interview conducted and copy of this report provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230522092645
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: CONTINUANCE CARE HOME LLC
FACILITY NUMBER: 019200807
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87405(a)
1
2
3
4
5
6
7
All facilities shall have a qualified and currently certified administrator... The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
mandatory meeting will be held at a later date.
8
9
10
11
12
13
14
Based on interviews, records review and observations, licensee did not comply with the above regulation. Facility administrator, Shirley Marshall, has not been involved in her administrative duties at least since March 2023, which poses a health and safety risks to persons in care
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5