415600133-3-23-2021-14-AS-KHOS-BZLNF2-20210330102451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600133
Report Date: 03/23/2021
Date Signed: 03/23/2021 03:53:00 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
05/20/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200520143002

FACILITY NAME:	ATRIA PARK OF 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: 92	DATE:	03/23/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Cecilia Dauth, Administrator		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Resident sustained stage 4 pressure injury while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Raygoza made an unannounced subsequent virtual complaint visit on the above allegation and met with Administrator, Cecilia Dauth.

Based on the Department's investigation of medical records, staff interviews, and medical interviews the following came forth: On 3/26/20, the Health Care Agency started wound care on a Stage 2 wound. On 4/6/20 LVN noted progression to Stage 3, which is a prohibited health condition, and notified the administrator. However, no exception request to retain the resident was submitted to CCL, and the licensee failed to seek higher level of care. On 4/17/20 it was noted that resident had two wounds that were unstageable. The available information shows that the home health nurse notified the licensee that the resident needed higher level of care for the wounds or 1:1 in order to timely attend to the needs of the resident; however, the facility failed to provide the necessary higher level of care, and failed to provide the 1:1 care the to meet the needs of the resident. By the time the licensee sought medical care, the wound had advanced to Stage 4. Therefore, the above allegation is SUBSTANTIATED.

Cont'd 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

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 3

Control Number 14-AS-20200520143002

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 PARK OF HILLSDALE	FACILITY NUMBER: 415600133
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/23/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 03/23/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a)Personnel Requirements - General - Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.	1 2 3 4 5 6 7	Training for Personnel requirements with training log to be submitted to CCL Office. POC to be submitted to CCL Office by 4/2/21.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: During the period of 4/06/20 through 4/23/20, facility did not ensure competent staff was disclosing and addressing R1's wounds.	8 9 10 11 12 13 14	An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. Civil Penalty in the amount of $10,000 for violation resulting to serious bodily injury is pending review. A non-compliance conference meeting will be scheduled.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20200520143002

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 PARK OF HILLSDALE	FACILITY NUMBER: 415600133
	VISIT DATE: 03/23/2021

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
26
27
28
29
30
31
32

Cont'd 9099
The above allegation is found to be substantiated, meaning that the allegation is valid because the preponderance of the evidence standard has been met.

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. Civil Penalty in the amount of $10,000 for violation resulting to Serious bodily injury is pending review. A non-compliance conference meeting will be scheduled.

This report was reviewed and discussed with Administrator, Cecilia Dauth.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3