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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800503
Report Date: 10/20/2020
Date Signed: 10/21/2020 08:01:39 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/28/2020 and conducted by Evaluator David Leibert
COMPLAINT CONTROL NUMBER: 21-AS-20200828130913
FACILITY NAME:SHALOM HOUSEFACILITY NUMBER:
216800503
ADMINISTRATOR:MARIA DEL PILAR DE OLAVEFACILITY TYPE:
740
ADDRESS:566 WAKEROBIN LANETELEPHONE:
(415) 491-0604
CITY:SAN RAFAELSTATE: CAZIP CODE:
94903
CAPACITY:5CENSUS: DATE:
10/20/2020
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria Del Pilar De OlaveTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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facility failed to address residents current care needs
facility failed to seek timely medical after an observed change of condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst Leibert contacted Administrator, Maria Del Pilar De Olave this date for the purpose of delivereing findings which have been amended from the prior report dated 10/01/2020. The modification of findings is the result of additional information received subsequent to 10/01/2020. The visit was done by tele-visit due to the COVID-19 precautions. R1 was admitted to the facility in February of 2020 with diagnosis of essential hypertension and history of stage 4 ulcer on heels, both resolved. R1 was seen on 8/12/20 by home health nurse and found to have pressure ulcer on coccyx; left leg; and right thigh, all unstageable. On 8/14/2020 R1 was admitted to medical facility and diagnosed with stage 3 ulcer on buttocks and stage 4 ulcer on right thigh. Faciliy's appraisal of R1 dated 2/19/20 and needs/appraisal plan dated 5/6/20 do not notate ulcers. There is no indication that R1 was reappraised prior to, or subsequent to, the discovery of unstageable ulcers on 8/12/2020 or prior to the hospital admittance on 8/14/2020. Based upon the review of records and the statement of witnesses, the preponderance of evidence standard has been met. Therefore, the allegations are SUBSTANTIATED.
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Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
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 3
Control Number 21-AS-20200828130913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: SHALOM HOUSE
FACILITY NUMBER: 216800503
VISIT DATE: 10/20/2020
NARRATIVE
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The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 21-AS-20200828130913
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: SHALOM HOUSE
FACILITY NUMBER: 216800503
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2020
Section Cited
CCR
87615(a)(1)
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87615(a)(1) PROHIBITED HEALTH CONDITIONS.Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(1) Stage 3 and 4 pressure injuries. Based upon witness statements, medical records,
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Administration is to review the requirements of 87615 and will develop protocols which will ensure compliance going forward. Protocols to be submitted to CCL for approval by POC date in order to clear the deficiency.
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 including home health notes, this requirement not met as evidenced by: Between 2/2020 and 8/14/20 R1 developed stage 3 and stage 4 pressure ulcers. Facility retained R1 until sent out for medical care on 8/14/2020. This presented an immediate risk to the health and safety of R1.
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Type B
10/30/2020
Section Cited
CCR
87463(a)
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87463(a)REAPPRAISALS.The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. Based upon records reviewed, this requirement has not been met as evidenced by: R1 developed a prohibited condition between 2/2020 and 8/12/2020 but was
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Administration is to review the requirements of 87463 and will develop protocols which will ensure compliance going forward. Protocols to be submitted to CCL for approval by POC date in order to clear the deficiency.
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not reappraised by facility staff subsequent to 5/6/2020. This presented a potential threat to the health and safety of R1.
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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.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David LeibertTELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3