216801830-4-9-2021-21-AS-KMOA-BZZLK3-20210412084848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216801830
Report Date: 04/09/2021
Date Signed: 04/09/2021 01:20:33 PM

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
03/24/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210324160536

FACILITY NAME:	L'CHAIM HOUSE		FACILITY NUMBER:	216801830
ADMINISTRATOR:	CARY KOPSTEIN		FACILITY TYPE:	740
ADDRESS:	777 MONTECILLO ROAD		TELEPHONE:	(415) 435-1395
CITY:	SAN RAFAEL	STATE: CA	ZIP CODE:	94903
CAPACITY:	6	CENSUS: 5	DATE:	04/09/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Cary Kopstein		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained multiple injuries from a fall while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA), Farhaan Sarangi made contact on this date, by phone, and conducted an unannounced virtual visit with the Administrator, Cary Kopstein for the purpose of delivering complaint findings and to close the complaint. An in-person complaint investigation inspection could not be done due to COVID-19 precautions.

Beginning on March 25, 2021 at approximately 10:35 AM, Licensing Program Analyst (LPA), Farhaan Sarangi investigated the above allegation. During the course of the investigation, LPA Sarangi interviewed the Administrator and reviewed various documents including resident records, LIC 602, the Care Plan for Resident 1 (R1) and the facility training hours for the Care Staff.

Complaint alleges that the resident sustained multiple injuries from a fall while in care. Based on an interview with the Administrator, LPA learned that the resident did fall and Care Staff at the facility did not send R1 to the Emergency Department (ED) after the fall. (Report continued on LIC 9099-C)

Substantiated

Estimated Days of Completion: 0

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

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-20210324160536

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: L'CHAIM HOUSE	FACILITY NUMBER: 216801830
	VISIT DATE: 04/09/2021

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

Facility waited two days to send R1 to the Emergency Department. During examination at the ED, it was determined that the resident did sustain multiple injuries during the fall. R1 had a small cut on their head indicating that they had hit their head. Although the responsible party was contacted, R1 was not sent to the Hospital until two days later. In addition, R1 is Non-Verbal and cannot state their own needs. A review of the LIC 602 and Care Plan indicate that R1 needs assistance with Daily Living functions. Furthermore, an incident report was submitted indicating the injuries sustained during the incident and the steps taken afterwards are as outlined in this report. A review of the facility training records indicate staff had training per regulation requirements.

Based on the information gathered, interviews conducted and the documents reviewed including but not limited to, the LIC 602, Care Plan and facility training records, the preponderance of evidence standard has been met, therefore the allegation of resident sustaining multiple injuries from a fall while in care are found to be SUBSTANTIATED.

California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given to the Administrator. Exit interview was conducted and a copy of this report was emailed to the Administrator for signature.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20210324160536

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: L'CHAIM HOUSE	FACILITY NUMBER: 216801830
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/09/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/09/2021 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	87465(g) Incidental Medical and Dental Care Services. 9-1-1 shall be telephoned immediately if an injury or other circumstance ... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to submit a plan and procedure regarding residents needing medical attention due to a fall/injury and how medical attention will be provided. Submit plan and procedure to CCL. Plan of Correction (POC) due date April 16, 2021.
	8 9 10 11 12 13 14	Based on LPAs documentation review and a interview with the Administrator, facility did not comply with regulation as it relates to contacting 911 immediately after an injury.	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: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3