019200807-11-29-2023-15-AS-HHUL-CZMQHP-20240119111129

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 LLC		FACILITY NUMBER:	019200807
ADMINISTRATOR:	MARSHALL, SHIRLEY		FACILITY TYPE:	740
ADDRESS:	565 SCHAFER RD		TELEPHONE:	(510) 398-8994
CITY:	HAYWARD	STATE: CA	ZIP CODE:	94544
CAPACITY:	16	CENSUS: 15	DATE:	11/29/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Mandar Kulkarni		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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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:

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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:

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
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)

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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

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...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).

SUPERVISORS NAME: Harpreet Humpal
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger
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)

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