415600133-3-29-2021-14-AS-KHOS-BZLP82-20210330110448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 03/29/2021
Date Signed: 03/29/2021 03:28:28 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
12/14/2020 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20201214151735

FACILITY NAME:	ATRIA HILLSDALE		FACILITY NUMBER:	415600133
ADMINISTRATOR:	PERRYMAN, DAVID		FACILITY TYPE:	740
ADDRESS:	2883 S NORFOLK ST		TELEPHONE:	(650) 378-3000
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	175	CENSUS:	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:			TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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- Facility lacks sufficient staff to meet residents' needs
- Facility staff are not qualified
- Facility staff member did not properly assess resident after falling
- Facility staff member did not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Han made a virtual complaint Tele-visit on the above allegations on behalf of Licensing Program Analyst (LPA) Raygoza and spoke with Administrator, Cecilia Dauth via phone and explaine the purpose of the call.

Regarding allegation that facility lacks sufficient staff to meet residents' needs, LPA Raygoza reviewed staff rosters and interviewed staff. Information provided at the time of filing indicates that the facility lacked 24/7 nursing care; no additional information is forthcoming from the complainant. The facility is an assisted living facility, not a skill nursing facility; therefore, no nursing care is required nor allowed. Based on the staff rosters and interviews there was sufficient staff on board to meet the residents’ needs.

Facility staff are not qualified. Based on the training logs submitted and interviews LPA Raygoza determined that the staff has attended the required training. The complainant indicated that a med tech was assigned to work at night instead of a nurse. RCFE regulations do not required a nurse to be part of the staff. No additional information is forthcoming from the complainant.

Regarding facility staff member did not properly assess resident after falling, the complainant stated that after a resident fell, the nurse on duty noted only a scratch; a day later, the resident had a bruise. The compliant failed to identify the resident, the time and date of the incident and no additional information is forthcoming from the complainant. The information available is insufficient to determine whether staff acted appropriately or not. Based on the fall training submitted for resident’s falls and staff interviews there is adequate proper training on Fall Risks.

Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

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-20201214151735

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: ATRIA HILLSDALE	FACILITY NUMBER: 415600133
	VISIT DATE: 03/29/2021

NARRATIVE

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Regarding the allegation that facility staff member did not treat resident with dignity and respect, the complainant stated that a resident wanted to talk to the Resident Service Director (RSD) regarding her plan of care, and the resident told the complainant that the RSD told her she is too busy. No additional information is forthcoming from the complainant. This is insufficient to formulate a potential violation. Furthermore, LPA Raygoza’s interviews indicate that staff is treating residents with respect and dignity.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated at this time.

Exit interview conducted with the Administrator, Cecilia Daugh over the phone. The Administrator will receive this LIC9099 and LIC9099C reports through email and will email LPA back the signed version by 3/29/2021.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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