385600432-2-23-2021-14-AS-KHOS-BYRN9L-20210303091608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600432
Report Date: 02/17/2021
Date Signed: 02/23/2021 04:40:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/02/2019 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20191002115237

FACILITY NAME:	PSALM RESIDENTIAL CARE HOME		FACILITY NUMBER:	385600432
ADMINISTRATOR:	ENCARNACION, WILLIAM, S		FACILITY TYPE:	740
ADDRESS:	565 GROVE ST		TELEPHONE:	(415) 621-8505
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	22	CENSUS: 17	DATE:	02/17/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jay Tacras and William Encarnacion		TIME COMPLETED:	09:45 AM

ALLEGATION(S):

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- Facility staff neglect resulted in resident developing severe infection(s)/necrosis

- Facility staff did not seek appropriate medical attention

- Facility staff did not order resident's medication

***********Virtual visit via FaceTime with staff Jay Tacras and administrator William Encarnacion**********

INVESTIGATION FINDINGS:

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Based on investigation conducted by this Dept.--which included review of medical records and interviews with facility staff, residents, medical professionals, and others--the preponderance of evidence standard has been met, therefore the above allegations are determined to be SUBSTANTIATED.
On 9/6/19 during medical appointment for another condition, client #1 was observed by PCP with foul smelling ulcers on legs; according to medical notes, client had 3 "large wounds" on lower extremeties "with copious d/c and erythema, open...cellulitis." He was sent to the emergency department due to concerns by the PCP, where the wounds "appear to be secondary to chronic venous stasis." In addition, his ear was observed with "erosions of necrosis." Tests were done at the ED, including x-rays for bone damage. PCP prescribed Cipro antibiotic. On 9/10/19, another antibiotic, Keflex, was prescribed. Although client was under the care of home health for wound treatment and was visited by RN on 9/2/19, staff failed to monitor client and contact PCP or home health for worsening wounds which required immediate medical intervention.
Client #1 was evaluated by DPM (podiatrist) on 8/30/19 and Clindomycin was prescribed for leg ulcers. However, staff failed to ensure that client got this antibiotic, as prescription was not filled.
***************This report is emailed to administrator, to be printed and signed, and returned to LPA via
email or fax at 650/266-8841 ************************************

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

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 14-AS-20191002115237

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: PSALM RESIDENTIAL CARE HOME	FACILITY NUMBER: 385600432
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/17/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/24/2021 Section Cited CCR 87466	1 2 3 4 5 6 7	OBSERVATION OF THE RESIDENT The licensee shall ensure that residents are regularly observed for changes in physical...functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as...deterioration of... a physical health condition are observed, the licensee shall ensure that such	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE, which shall include how licensee will ensure that clients are regularly observed by staff for changes in condition and unmet needs.
	8 9 10 11 12 13 14	changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met, as licensee failed to observe worsening condition of client #1 leg wounds & seek immediate medical care, which posed an immediate health & safety risk to client.	8 9 10 11 12 13 14
Type A 02/24/2021 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	INCIDENTAL MEDICAL CARE The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as DPM of client #1 prescribed antibiotic on 8/30/19, but facility staff failed to obtain this information from DPM and get prescription filled. Licensee failed to ensure that client #1	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE, which shall include process for following up with clients' medical providers to ensure that prescribed medications are filled immediately.
	8 9 10 11 12 13 14	received antibiotic as prescribed, which posed an immediate health and safety risk to client.	8 9 10 11 12 13 14

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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2021

LIC9099 (FAS) - (06/04)

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