415600080-12-30-2022-14-AS-CSMH-CMRU6C-20230104141805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600080
Report Date: 12/30/2022
Date Signed: 12/30/2022 09:23:00 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
10/03/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221003115901

FACILITY NAME:	SAN MATEO VILLA		FACILITY NUMBER:	415600080
ADMINISTRATOR:	VIDUCICH, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	1661 MCKINLEY STREET		TELEPHONE:	(650) 570-6475
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	12/30/2022
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Caregiver, Emely De La Cruz		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Staff neglected the care for resident resulting in resident sustaining a pressure 4 injury.

INVESTIGATION FINDINGS:

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On December 30, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to the facility to deliver the findings for the above allegation. LPA met with Caregiver, Emely De La Cruz and explained the prupose of the visit.

Regarding the allegation that staff neglected the care for resident resulting in resident sustaining a pressure 4 injury, according to the reporting party, Resident #1 (R1) was seen in the clinic at Mills Peninsula on 10/3/22 for a stage 4 pressure ulcer left heel and deep tissue right posterior ankle. In addition, the reporting party indicated that the R1 was receiving Home Health Services with Harmony Home Health.

During the investigation, the Department reviewed R1’s medical records and interviewed R1’s responsible party and R1’s doctor. Based on the medical records reviewed, R1 did have a stage 4 pressure injury on his/her left heel, however during the time of the injury, the home health agency was responsible for R1’s pressure injury. According to R1’s responsible party, on 8/16/22, the facility notified him/her that R1 was starting to develop a pressure injury. The responsible party called the wound clinic and the doctor approved R1 to receive home health services from Harmony Home Health and for the home health nurse to follow the pressure injury.

According to R1’s doctor, the facility was not responsible for caring for R1’s pressure injury and that there was no suspicion of neglect on behalf of the facility. Furthermore, according to the Licensee, the facility was in daily communication with R1's responsible party and his/her doctor.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed with Caregiver and a copy is provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2022

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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