216800503-10-8-2020-21-AS-CMAZ-BURL5S-20201026082736

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800503
Report Date: 10/01/2020
Date Signed: 10/08/2020 08:27:44 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 HOUSE		FACILITY NUMBER:	216800503
ADMINISTRATOR:	MARIA DEL PILAR DE OLAVE		FACILITY TYPE:	740
ADDRESS:	566 WAKEROBIN LANE		TELEPHONE:	(415) 491-0604
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	5	CENSUS:	DATE:	10/01/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Maria Del Pilar De Olave		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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facility failed to report

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert met with Administrator Pilar de Olave, this date, for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via tele-visit due to the COVID - 19 precautions. LPA did not physically present at the site. It has been alleged that the facility did not make an Unusual Incident/Injury Report to the required parties following a medical complication necessitating a call to 911 for resident R1. In response to the allegation, this Department has reviewed records and taken statements. The following determinations have been made: R1 was sent out for medical attention on August 14, 2020; Facility Administrator notified this Agency by phone and by fax as well as other agencies entitled to notice on August 15, 2020. Based upon the statements taken and the records reviewed, we have determined that the complaint is UNFOUNDED, meaning that the allegation is false, did not happen, or is without a reasonable basis. Therfore, the complaint is dismissed.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

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

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 HOUSE		FACILITY NUMBER:	216800503
ADMINISTRATOR:	MARIA DEL PILAR DE OLAVE		FACILITY TYPE:	740
ADDRESS:	566 WAKEROBIN LANE		TELEPHONE:	(415) 491-0604
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	5	CENSUS:	DATE:	10/01/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Maria Del Pilar De Olave		TIME COMPLETED:	02:00 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

******THIS DOCUMENT IS AMENDED AS A RESULT OF RECEIVING ADDITIONAL INFORMATION THAT SUBSTANTIATES THE ALLEGATIONS. DUE TO TECHNICAL REQUIREMENTS A NEW REPORT (9099A) HAS BEEN GENERATED. PLEASE REFER TO THE COMPLAINT INVESTIGATION REPORT OF 10/20/2020.****

INVESTIGATION FINDINGS:

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Licensing Program Analyst Leibert met with Administrator Pilar de Olave, this date. for the purpose of delivering findings on the above captioned complaint allegation. The visit was conducted via Tele - Visit due to the COVID - 19 precautions. Complainant alleges that R1 developed pressure ulcers and deteriorating health while in residency at facility and that staff failed to address R1's needs and did not seek timely medical care for R1. In response to the allegations, this Department has obtained statements from witnesses and reviewed facility records, medical records, and correspondence. The following determinations have been made: R1 was admitted to a medical facility on 8/14/2020 with a diagnosis of respiratory issues, pressure ulcer, and sepsis; The date of onset for the medical issues is not known but records indicate R1 came to Shalom House from an acute care facility with a history of skin problems, sepsis, and failure to thrive; Family member and Responsible Party for R1 state that R1 received good care while at the facility; Responsible Party reports that concerns regarding the COVID - 19 virus made it difficult to obtain out patient care for R1 and that medical personnel may have advised against taking R1 out of facility for treatment; Two physicians who treated R1 recently were contacted for opinions regarding R1's condition and care. *CONTINUED ON SECOND PAGE*

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

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 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: 10/01/2020

NARRATIVE

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As of this date, no response has been received from either physician.

Although the allegations may have happened, or are valid, based upon statements and interviews obtained by LPA, there is not a preponderance of evidence to prove the alleged violations did, or did not, occur. Therefore, the allegations are UNSUBSTANTIATED.

No deficiencies noted this date.

Copy of report provided to facility.

******THIS DOCUMENT IS AMENDED AS A RESULT OF RECEIVING ADDITIONAL INFORMATION THAT SUBSTANTIATES THE ALLEGATIONS. DUE TO TECHNICAL REQUIREMENTS A NEW REPORT (9099A) HAS BEEN GENERATED. PLEASE REFER TO THE COMPLAINT INVESTIGATION REPORT OF 10/20/2020.****

SUPERVISOR'S NAME: Carla Martinez	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: David Leibert	TELEPHONE: (707) 588-5086
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2020

LIC9099 (FAS) - (06/04)

Page: 3 of 3