410508359-9-27-2024-14-AS-ACON-D9VVUR-20241009164508

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410508359
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:43:36 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
05/14/2024 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240514110539

FACILITY NAME:	PENINSULA REGENT (THE)		FACILITY NUMBER:	410508359
ADMINISTRATOR:	MARTIN HERTER		FACILITY TYPE:	741
ADDRESS:	1 BALDWIN AVENUE		TELEPHONE:	(650) 579-5500
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	435	CENSUS: 203	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Martin Herter and Leona Martin		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not ensure call button alerts are responded to in a timely manner
Resident sustained an injury while in care
Staff do not ensure residents are spoken to in an appropriate manner
Staff handle residents in a rough manner

INVESTIGATION FINDINGS:

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LPA Jeung met with executive director and health and wellness director to discuss allegations regarding client #1 and reviewed client file, including emergency call system log of responses to client #1 from 4/1/24 to 5/21/24. Care staff was interviewed.

Based on information reported by staff and review of facility records, these allegations are substantiated. The preponderance of evidence standard has been met.

As per review of facility's Alarm History Report of emergency calls from room 123--where client #1 resides--for period 4/1 - 5/21/24, it is noted that client activated the alarm frequently; alerts were recorded almost daily, and several times on each day. On at least 16 occasions over the period of 51 days, staff responded 15 minutes or more after the alert was activated.

Continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2024

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 4

Control Number 14-AS-20240514110539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PENINSULA REGENT (THE)	FACILITY NUMBER: 410508359
	VISIT DATE: 09/27/2024

NARRATIVE

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Continued from page ONE

Incident of 5/4/24 was documented and reported to licensing agency after client's family observed discoloration on client's arms and a skin tear. Upon facility's investigation, a staff was found to be responsible for handling client roughly, resulting in bruises and skin tear on client's arms. In addition, this staff did not respect client's wishes to rest instead of getting up for breakfast; she was perceived as rude and impatient when interacting with client. Facility terminated this staff on 5/15/24.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
05/14/2024 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20240514110539

FACILITY NAME:	PENINSULA REGENT (THE)		FACILITY NUMBER:	410508359
ADMINISTRATOR:	MARTIN HERTER		FACILITY TYPE:	741
ADDRESS:	1 BALDWIN AVENUE		TELEPHONE:	(650) 579-5500
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	435	CENSUS: 203	DATE:	09/27/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Martin Herter and Leona Martin		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not ensure residents receive bathing assistance
Staff do not ensure residents receive toileting assistance in a timely manner

INVESTIGATION FINDINGS:

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Based on facility records reviewed and interviews with staff, these allegations are determined to be unsubstantiated. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

As per facility's Individual Service Plan Report obtained on 5/21/24, staff provide extensive assistance to client 3 times per week to bathe or shower and assist with incontinence care and scheduled toileting. There is also documentation that client sometimes was resistant to care and refused service. On some occasions, staff assisted client with sponge baths instead of showers.
Based on facility's ADL log, staff acknowledge provision of daily care provided--bathing/showering, bathroom assistance/toileting. In addition, staff initial a paper log to record "bathroom assistance, found in bathroom,briefs changed." Resident summons staff when assistance is needed by activating an emergency call alert. Although staff did not consistently respond to client's calls in a timely manner, it cannot be proven that staff failed to provide timely toileting assistance.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20240514110539

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: PENINSULA REGENT (THE)	FACILITY NUMBER: 410508359
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/04/2024 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as client #1 sustained an injury when a staff handled	1 2 3 4 5 6 7	Staff LVN is no longer employed at facility as a result of interactions with this resident. Plan of correction to be submitted to CCLD BY DUE DATE, documenting how this situation was addressed, and what facility has done to avoid a recurrence
	8 9 10 11 12 13 14	client in rough manner. Licensee failed to accord client the right to be treated with dignity and respect in relationship with staff, which posed a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 10/04/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	ADDITIONAL PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement was not	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE, describing how facility will ensure that residents calls for assistance will be monitored for timely responses
	8 9 10 11 12 13 14	met, as staff failed to respond to client's call alerts in a timely manner. Licensee failed to ensure that staff were sufficient in numbers and competency to respond to client's needs in timely manner. This posed a potential health, safety, or personal rights risk to clients in care.	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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC9099 (FAS) - (06/04)

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