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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508446
Report Date: 06/21/2022
Date Signed: 06/21/2022 10:43:37 AM

Substantiated


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
01/13/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220113095628
FACILITY NAME:VANESSA CARE HOME IIFACILITY NUMBER:
410508446
ADMINISTRATOR:GALATI, IDAFACILITY TYPE:
740
ADDRESS:1640 ELEANOR DRIVETELEPHONE:
(650) 863-4262
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator, Ida GalatiTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Facility failed to report incident
Facility is not assisting resident with incontinence care
Staff are using resident’s supplies on other residents
INVESTIGATION FINDINGS:
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On June 21, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator/Licenesee, Ida Galati and explained the purpose of the visit.

Regarding the allegation that the facility failed to report an incident, on January 7, 2022, Resident #1 (R1) was ringing his/her bell for assistance in the evening, but the facility failed to respond resulting in R1 calling 911 for assistance instead. During the investigation, LPA interviewed the administrator and she admitted to not reporting to Licensing because the resident did not have any falls or injuries.

Based on the information collected and interviews conducted, it was determined that facility failed to report an incident. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated. (CONT. TO 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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 6
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
01/13/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220113095628

FACILITY NAME:VANESSA CARE HOME IIFACILITY NUMBER:
410508446
ADMINISTRATOR:GALATI, IDAFACILITY TYPE:
740
ADDRESS:1640 ELEANOR DRIVETELEPHONE:
(650) 863-4262
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: DATE:
06/21/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee/Administrator, Ida GalatiTIME COMPLETED:
10:50 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to respond to an emergency and resident had to call 911 to obtain assistance
Resident sustained pressure injuries while in care
Facility refused to return resident’s belongings
INVESTIGATION FINDINGS:
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13
On June 21, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced visit to deliver the findings for the above allegations. LPA met with Licensee/Administrator, Ida Galati, and explained the purpose of the visit.

Regarding the allegation that the facility failed to respond to an emergency and resident had to call 911 to obtain assistance, according to the complainant, on January 7, 2022, Resident #1 (R1) rang her bell for 90 minutes because he/she was in pain and needed assistance, but staff failed to respond resulting in R1 calling 911 for assistance instead. During the investigation, LPA interviewed Staff #1 (S1) who was present at the time of the incident, and it was indicated that when the police arrived, S1 and the police both observed R1 and he/she was lying down in bed. In addition, S1, indicated that the police stayed for a couple minutes, talked to R1 and left. No examinations were done by the police and the ambulance was not called.

Therefore, based on the information collected, and interviews, the allegation that the Facility failed to respond to an emergency and resident had to call 911 to obtain assistance is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. (CONTINUE TO 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
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 6
Control Number 14-AS-20220113095628
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: VANESSA CARE HOME II
FACILITY NUMBER: 410508446
VISIT DATE: 06/21/2022
NARRATIVE
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Regarding the allegation that resident sustained pressure injuries while in care, according to the complainant, R1 developed bed sores the same week of the incident that had occurred on January 7, 2022 because R1 was incontinent. In addition, complainant indicated that the Administrator stated R1 had a rash, not a bedsore. During the investigation, it was acknowledged by interviewed staff that R1 laid in bed most of the time from being in pain. However, staff indicated that there was no record of any pressure injuries sustained by R1 during the time at the facility.

Therefore, based on the information collected, and interviews conducted, the allegation that resident sustained pressure injury(ies) while in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Regarding the allegation that facility refused to return resident’s belongings, according to the complainant, R1’s occupational therapist ordered DME supplies for him/her which included: a walker, a bedside commode, a wheelchair with a gel cushion. When R1’s responsible party was planning to transfer R1 to a new facility, they were going to take the supplies, however, the staff insisted the supplies belonged to the facility. During the investigation, LPA interviewed staff members and it was indicated that R1’s responsible party was trying to take the supplies but the staff wanted to keep the supplies because R1 was still a resident at the facility and the staff wanted to continue using it for R1. In addition, according the administrator, there was a misunderstanding since the facility was unaware that R1 was going to be moved to a new facility. Nevertheless, the facility did give R1's belongings to R1's responsible party when R1 left the facility.

Therefore, based on the information collected, and interviews conducted, the allegation that the facility refused to return resident's belongings is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report reviewed with the Administrator, and a copy is provided with the appeals rights is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20220113095628
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: VANESSA CARE HOME II
FACILITY NUMBER: 410508446
VISIT DATE: 06/21/2022
NARRATIVE
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Regarding the allegation that the facility is not assisting resident with incontinence care, according to the complainant, R1 gets changed 2x a day, during the morning and at night. During the investigation, LPA reviewed R1’s file and it was indicated that R1 was incontinent and needed max assist with toileting needs. According to interviewed staff, it was indicated that R1 would get changed 2-3x a day. In addition, the administrator indicated that there was no care plan for R1’s toileting needs and that the facility tried to change R1 when he/she was wet.

Based on the documents reviewed and the interviews conducted, it was determined that the facility is not assisting resident with incontinence care. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Regarding the allegation that the staff are using resident’s supplies on other residents, according to the complainant, the home health nurse ordered wound are supplies for R1. The complainant indicated that the box of supplies were open and the administrator admitted to using the supplies on other residents. During the investigation, LPA interviewed the administrator and the administrator indicated that R1 had a rash and she had used another resident’s supplies because she was waiting for R1’s supply package to get delivered. Although the administrator didn’t admit to using R1’s supplies on another resident, she did admit to using another resident’s supplies on R1.

Based on the interviews conducted, it was determined that the facility staff are using resident’s supplies on other residents. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report reviewed with the administrator, and a copy is provided with the appeals rights is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20220113095628
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: VANESSA CARE HOME II
FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2022
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below…

Violation of this regulation is not met as evidenced by:
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Licensee/administrator to conduct training regarding reporting requirements. In addition, Licensee/administrator will submit acknowledgement regarding CCR 87211 Reporting Requirements to CCLD by 6/28/22.
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Facility failed to report an incident that occurred on January 7, 2022 as required to Licensing. In addition, facility failed to submit a written report within 7 days of the occurrence date of the incident.
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Type B
06/28/2022
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence: (b)In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (2) Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night.

Violation of this regulation is not met as evidenced by:


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Licensee to conduct in-service training regarding incontinent care. Licensee will have a care plan for each incontinent resident and ensure it is up to date.
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Based on the file reviewed and the interviews conducted, R1 was incontinent and needed max assist with toileting needs, however the facility did not have a care plan to ensure that R1’s incontinent condition and needs can be met. Nevertheless, the administrator indicated that there was no care plan for R1.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20220113095628
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: VANESSA CARE HOME II
FACILITY NUMBER: 410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2022
Section Cited
CCR
87307(a)(3)
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87307 Personal Accomodations: (a) Living accommodations and grounds...the facility shall be large enough to provide... accommodations...for the residents... (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice… shall be readily available to each resident...

Violation of this regulation is not met as evidenced by:
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Licensee will ensure that supplies needed for resident care will be readily available.
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Based on the information collected, the licensee failed to ensure R1 had the necessary supplies available, as evidenced by the administrator using other resident's supplies on another resident. The supplies were not readily available and the administrator acknowledged using another resident’s supplies.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6