415600133-4-14-2023-14-AS-AJEG-CQVMEG-20230414093244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600133
Report Date: 04/14/2023
Date Signed: 04/14/2023 09:33:04 AM

Document Has Been Signed on 04/14/2023 09:33 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ATRIA PARK OF SAN MATEO		FACILITY NUMBER:	415600133
ADMINISTRATOR:	JENNIFER DUENAS		FACILITY TYPE:	740
ADDRESS:	2883 S NORFOLK ST		TELEPHONE:	(650) 378-3000
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	175	CENSUS: 79	DATE:	04/14/2023
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Kim Sims and Mark Pagaduan		TIME COMPLETED:	09:45 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	Licensing Program Analysts (LPA) Donato and Jeung met with Mark Pagaduan, Engage Life director in the absence of facility administrator to follow up on a substantiated complaint allegation of failure to observe residents’ personal rights to provide residents a safe environment, which resulted in death of two residents, R1 and R2, and serious bodily injuries resulting in hospitalization of R3. On 2/2/23, the licensee was cited for violating the California Code of Regulations (CCR) Title 22, §87468.1 Personal Rights of Residents in All Facilities, which states residents in all residential care facilities for the elderly shall have the right to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. The licensee violated residents’ personal rights when Staff 4 (S4) provided chemicals to R1, R2, R3. As a result, they sustained serious burns to their mouths, esophagus and stomach leading to necrotizing tissue. The licensee was further cited under CCR Title 22, § 87309 Storage Space, which states that disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients; §87555 General Food Service Requirements, which states detergents, cleaning compounds or similar substances shall be stored in areas separate from food supplies; §87411 Personnel Requirements – General, which states personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs; and §87405 Administrator - Qualifications and Duties, which states the administrator shall have the responsibility to administer the facility in accordance with these regulations and established policy, program and budget. The investigation included interviews with staff and possible witnesses, and reviews of facility, personnel, residents’ records, facility camera video footage, medical records, police report and San Mateo County 9-1-1 audio recording and computer-aided dispatch report.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2023

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

LIC809 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA PARK OF SAN MATEO	FACILITY NUMBER: 415600133
	VISIT DATE: 04/14/2023

NARRATIVE

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On 08/27/2022, based on staff interviews, Staff 1 (S1)--who usually works in Life Guidance (LG) unit--was assigned to work in another kitchen (Section 1). S1 noticed the dishwashing detergent/chemicals was running low and asked Staff 2 (S2) to bring dishwasher detergent/chemicals to refill the dishwasher in the Section 1 kitchen. S2 retrieved the large 5-gallon bucket of dishwashing detergent/chemicals from the large kitchen and brought it to S1. During the investigation, it was revealed that for weeks prior to the incident related to this complaint, the facility had run out of one-gallon dispensing jugs of the dishwashing detergent/chemicals. Instead of resupplying the one-gallon jugs, the licensee purchased five-gallon buckets of the dishwasher detergent/chemicals.

Per investigation, the dishwasher detergent/chemicals brand in the facility is Ecotemp Ultra Klene dishwashing detergent.

S1 reported that she had used a beverage pitcher, in the past, to transfer the dishwashing detergent/chemicals from the five-gallon bucket to the one-gallon detergent dispenser. S1 instructed S2 to use the beverage pitcher for the dishwashing detergent/chemicals.

Staff 3 (S3) saw S2 using the beverage pitcher for the dishwashing detergent/chemicals but failed to say anything to S2 about not using the beverage pitcher and S3 failed to report to anyone that the beverage pitcher was used to transfer the dishwashing detergent/chemicals.

S2 left the beverage pitcher with S1 and failed to confirm the transfer occurred. S1 did not pour the detergent into the one-gallon detergent dispenser right away and instead left the beverage pitcher on the counter, next to the sink. Neither S1 nor S2 labelled the beverage pitcher as dishwashing detergent/chemicals. S4 picked up the beverage pitcher not knowing the beverage pitcher contained the dishwashing detergent/chemicals and served the contents to R1, R2, and R3. Upon being served, R1’s lips began to swell and was black and red in color. R2 yelled after drinking out of the juice cup and then sat down. S1 said “it’s soap.” S4 was confused as the dishwashing detergent/chemicals was the same color as cranberry juice. S4 asked other staff to call 9-1-1. S4 did not know when poison control was supposed to be called.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA PARK OF SAN MATEO	FACILITY NUMBER: 415600133
	VISIT DATE: 04/14/2023

NARRATIVE

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Upon observing that R1, R2, and R3 were having a adverse reactions, facility staff members called 9-1-1. San Mateo Consolidated Fire Department (SMCFD) and AMR (medical transportation) arrived, in response to the call. S5, who was the manager on duty, stated to the Fire Chief that a resident went into the kitchen and poured glasses of the dishwashing detergent/chemicals and gave them to other residents to drink. S5 and a member of SMCFD called Poison Control to inquire about the ingestion of the dishwashing detergent/chemicals by the residents. R1, R2, and R3 were all transported to nearby hospitals.

After being admitted to the hospital, R1’s condition deteriorated, and he expired.

R1’s coroner’s report revealed that listed as one of R1’s anatomical diagnoses were: Ingestion of highly alkaline fluid (a) chemical burns, oral cavity, esophagus, and stomach. The death certificate indicates that the cause of death was ingestion of alkaline cleaning solution.

Based on hospital records, R2 was admitted in acute respiratory distress requiring intubation. R2’s condition gradually deteriorated and R2 expired. The death certificate indicates the cause of death as medical complications following ingestion of alkaline cleaning solution.

Based on hospital records review, R3 presented with burns in the mouth, lips, and tongue. R3 was discharged to a higher level of care. R3’s discharge diagnoses to a higher level of care includes but is not limited to the acute ingestion of Ecotemp Ultra Klene (machine wash detergent).

Based on interviews and facility records, there were no instructions on how to pour the detergent from the five-gallon bucket to the one-gallon detergent dispenser. LG caregivers did not receive training for handling chemicals since they were not kitchen staff, even though they were assigned to kitchen duties.

At the time of the complaint visit on 02/02/2023, an immediate $500.00 civil penalty was assessed and the licensee was informed that an additional civil penalty was pending review based on Health and Safety Code
§ 1569.49.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA PARK OF SAN MATEO	FACILITY NUMBER: 415600133
	VISIT DATE: 04/14/2023

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The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. 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.”

Today, 4/14/23, 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 resulting in the deaths of R1 and R2, in the amount of $30,000 ($15,000 for death of each resident) and serious bodily injuries resulting in hospitalization and a higher level of care for R3, in the amount of $10,000. However, since a $500.00 civil penalty was issued on 02/02/2023 the civil penalty today will be $39,500.00.

Exit interview conducted. A copy of this report is provided to Mark Pagaduan, with LIC421D to assess $39,500 civil penalty. Mr. Pagaduan's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023

LIC809 (FAS) - (06/04)

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