385600418-4-26-2022-14-AS-MHAN-CDUPE2-20220426111426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600418
Report Date: 04/26/2022
Date Signed: 04/26/2022 11:14:42 AM

Document Has Been Signed on 04/26/2022 11:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	QUALITY CARE HOMES, LLC 3		FACILITY NUMBER:	385600418
ADMINISTRATOR:	CESAR ARES		FACILITY TYPE:	740
ADDRESS:	2277 - 33RD AVENUE		TELEPHONE:	(415) 661-3477
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	0	CENSUS:	DATE:	04/26/2022
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Caregiver, Rosema Caspillan		TIME COMPLETED:	11:30 AM

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	On 4/25/2022, Licensing Program Analyst (LPA) Murial Han met with caregiver from Quality Care Homes, LLC 2, Rosema Caspillan for a Case Management visit to follow up on a substantiated complaint regarding neglect/lack of care and supervision. Caregiver informed the administrator of LPA's visit over the phone and LPA Han explained the purpose of today's visit. On November 8, 2016, the Department concluded a complaint investigation which alleged the following: Due to neglect, a resident (R1) sustained stage 3 and unstageable pressure injuries while in care; R1 was hospitalized due to facility negligence; and facility staff failed to seek timely medical attention; which resulted in R1 passing away in the hospital due to septic shock. The allegations were substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § 87466 Observation of R1 for the licensee failed to regularly observe for changes in physical, mental, emotional, and social functioning, and that appropriate assistant is proved when such observation reveals unmet needs. When changes such as unusual weight gains, losses, or deterioration of mental ability or a physical health condition are observed; the licensee shall ensure that such changes are documented and brought to the attention of R1’s physician and R1’s responsible person, if any. The licensee was further cited for CCR Title 22, § 87465(a)(2) Incidental Medical and Dental Care Services for the licensee failed to seek higher level of care or immediate medical attention for R1, which the facility did not call 9-1-1 upon R1’s initial signs of health decline and observation of a pressure ulcer.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: QUALITY CARE HOMES, LLC 3	FACILITY NUMBER: 385600418
	VISIT DATE: 04/26/2022

NARRATIVE

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The investigation revealed that R1 was placed on June 3, 2016, from an acute care hospital. Per facility staff interviews, R1 was talkative and needed some assistance with walking and bathing. Staff also reported they were aware that R1 had pressure injuries (stage of injuries were unknown). Between June 25, 2016 and June 26, 2016, R1 was noted scratching R1’s bottom. On June 29, 2016, the licensee attempted to contact R1’s Primary Care Physician (PCP) to refill medication to prevent pressure injuries and request Home Health, but R1’s PCP was on vacation. Facility Director was also aware R1’s PCP was on vacation but did not take R1 to Urgent Care or to the hospital emergency room.

The investigation revealed that on July 3, 2016, staff (S1) noted that R1 was coughing, less communicative, and lethargic after breakfast. At around 10:00 a.m. and 11:00 a.m., R1 was pale and had a hard time breathing. S1 did not notify R1’s responsible party, PCP, and or call 9-1-1 at that time. S1 states that S1 fed R1 during lunch time. Facility staff called 9-1-1 (time unknown) as R1 was pale and had trouble breathing.

According to the local fire department records, on July 3, 2016 (2:54 p.m.), R1 was found on R1’s side on R1’s bed, with difficulty breathing, hot to touch, responsive to painful stimuli only, and had an episode of vomiting earlier in the day. Facility staff stated that R1 was normally verbal and converse but had been less responsive for a week. Facility staff stated, “R1 was sick last night,” but no response from facility staff when asked why staff did not call 9-1-1 sooner. R1 with audible rhonchi (abnormal lung sounds- mayoclinical.org), labored breaths, no change in respirations when R1 was sat up higher in bed. R1’s blood pressure 74/50 (low blood pressure below 90/60- mayoclinical.org), EKG ST 118 (sinus Tachycardia – fast heartbeat (normal 60-100 beats/minute)- mayoclinic.org), provided with high flow O2 non- breathable (NRB) mask, O2 sat up to 96 percent after. NO was 94/60 after IV fluids bolus 250 ml x 2 was given.

On July 3, 2016, R1 was transported via paramedics and admitted to a general acute care hospital. R1’s wounds were present on admission to the hospital: stage 2 right buttocks, shallow open ulcer with red pink (not yellow) wound bed without slough or serum filled blister; stage 3 left ischium full thickness tissue loss, no bone or tendon or muscle exposed. Slough does not occur depth of tissue loss. R1’s right hip unstageable, full tissue loss in which the base of the ulcer is covered with slough or eschar. Right ischium unstageable full tissue loss in which the base of the ulcer is covered with slough or eschar. Lateral right foot suspected deep tissue loss - purple or maroon localized areas of the discolored intact skin or blood-filled blister.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: QUALITY CARE HOMES, LLC 3	FACILITY NUMBER: 385600418
	VISIT DATE: 04/26/2022

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According to the Critical Care Medical Notes, R1 had the following diagnoses: severe sepsis/septic shock , Encephalopathy (per mayoclinic.org, brain degeneration likely caused by repeated head traumas), and Urosepsis (per mayoclinic.org, is an important complication after percutaneous nephrolithotomy). According to Mayo Clinic Sepsis is a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues. When the infection-fighting processes turn on the body, they cause organs to function poorly and abnormally. Sepsis may progress to septic shock. This is a dramatic drop in blood pressure that can lead to severe organ problems and death.

On July 5, 2016, R1 was extubated and R1 continued to decline with medical condition. R1 passed away on July 30, 2016, at the hospital. R1’s cause of death based on the Death Certificate, was senile dementia with secondary diagnoses of septic shock and urinary tract infection (UTI).

Based on observation, interviews, and record review, the licensee did not seek higher level of care or immediate medical attention when R1’s health was declining. The licensee did not obtain timely emergent care for R1 which caused R1 to be hospitalized, diagnosed with pressure injuries, and sepsis shock, which is serious bodily injury.

At the time of the complaint visit on November 8, 2016, an immediate $150 civil penalty was issued and the licensee was informed that an additional civil penalty was still being determined and might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. Per Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including, but not limited to, hospitalization, surgery, or physical rehabilitation.”

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: QUALITY CARE HOMES, LLC 3	FACILITY NUMBER: 385600418
	VISIT DATE: 04/26/2022

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Today 4/26/2022, the Department is issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as a serious bodily injury in the amount for $10,000. However, since a $150 civil penalty was issued on November 8, 2016, the penalty civil today will be $9,850.

Exit interview conducted. A copy of the report issued. Appeal Rights provided.

Facility representative did not feel comfortable signing the reports including the LIC421D. However, it was explained and presented to the administrator over the phone.

A copy of the LIC421D is provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2022

LIC809 (FAS) - (06/04)

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