415600184-8-31-2021-14-AS-MHAN-C6EP42-20210831105825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600184
Report Date: 08/31/2021
Date Signed: 08/31/2021 10:58:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ATRIA BURLINGAME		FACILITY NUMBER:	415600184
ADMINISTRATOR:	JEFF SUMABAT		FACILITY TYPE:	740
ADDRESS:	250 MYRTLE RD		TELEPHONE:	(650) 343-2747
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	90	CENSUS: 45	DATE:	08/31/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Jeff Sumabat		TIME COMPLETED:	11:10 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	On 8/31/2021 Licensing Program Analyst (LPA) Murial Han met with the Administrator, Jeff Sumabat for a case management visit to follow up on a substantiated complaint allegation of neglect/lack of supervision. On March 13, 2017, the Department concluded a complaint investigation which alleged that the licensee failed to provide timely medical care for resident (R1) that sustained a fall that resulted in a left radial head fracture on the left arm. The allegation was substantiated and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87211(a)(1)(D)” Reporting Requirements for failure to report to the Hospice agency that R1 sustained injury due to a fall. The licensee was further cited under CCR Title 22, § “87465(a)(1)” Incidental Medical and Dental Care for failure to obtain timely medical treatment and calling 9-1-1 when hospice did not come to the facility to assess the resident. Hospice received a call from facility stating that resident had a fall and that there was no injury. Facility staff also denied a need for a nurse to come out. R1 was sent to the hospital to be evaluated after being seen by Hospice RN who noted the swelling and bruising on R1’s left arm the day after the fall. The investigation revealed that R1 requires status checks every 2 hours due to history of falls. On October 23, 2016, R1’s arm was broken due to a unwitnessed fall in the facility which resulted in a displaced fracture to the head of the radial bone in R1’s left arm. Facility documentation for October 25, 2016 noted that R1 was not in pain. On October 28, 2016, facility submitted an addendum regarding the incident which noted that hospice was called on October 24, 2016, due to R1 was not feeling well and was expressing pain. The facility did not inform Hospice or PCP about the injury or seek medical attention via urgent care or emergency medical services until insisted upon by Hospice on October 24, 2016.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA BURLINGAME	FACILITY NUMBER: 415600184
	VISIT DATE: 08/31/2021

NARRATIVE

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On October 24, 2016 Home Health RN went to the facility to visit R1 at approximately 10:00 a.m. (more than 24 hours after R1’s fall). R1’s left arm looked “really bad” – severely swollen and discolored black and blue. R1 communicated to RN that R1 had knee and elbow pain. R1 was moaning a lot with R1’s eyes closed and was not very alert. Facility caregivers should have noticed the swelling on R1’s left arm when they dressed R1 that morning since R1 was fully dressed. R1 should have been observed after R1’s fall to check for pain or any injury that developed. On the morning of October 24, 2016, RCFE directors claimed they observed the swelling on R1’s left arm and called MHHC for advice, however there was no record of this call.

On October 24, 2016, at approximately 1:43 p.m., R1 was admitted to a general acute care hospital, via non-emergency transport, with a diagnosis of displaced fracture to the head of the left radical, initial encounter for closed fracture. The Mayo Clinic defines closed fracture as broken bone with the skin remain unbroken. A hematoma was also noted on the area of R1’s left elbow. R1 said R1 pain level was 10/10. R1 had a shoulder splint with swath (shoulder immobilizer) and was discharged safely back to the facility with outpatient re-evaluation in orthopedic surgery.

According to the medical records dated October 24, 2016, R1 was presented at the emergency room with circumferential bruising around the left elbow, as well as elbow pain/tenderness. The hospital diagnosed R1 with a displaced fracture of head of left radius, initial encounter for closed fracture. Additionally, it was also noted that R1 had an acute neck fracture, when R1 was examined in the emergency room the day after the fall.

Based on the documents reviewed, the licensee did not assess R1 completely for injuries after R1’s fall. Although Hospice was informed of the fall, the licensee failed to notify Hospice or R1’s PCP for R1’s left arm redness and swelling. The licensee did not seek immediate medical attention when hospice did not come to the facility to assess R1 within 24 hours. The licensee did not obtain timely medical care for R1 which resulted in R1 being diagnosed with circumferential bruising around the left elbow, as well as severe elbow pain/tenderness, and a radial head fracture on the left arm that required hospitalization which is a serious bodily injury.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ATRIA BURLINGAME	FACILITY NUMBER: 415600184
	VISIT DATE: 08/31/2021

NARRATIVE

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At the time of the complaint visit on March 14, 2017, the issuance of a civil penalty was still being determined. On August 31, 2021, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49.

The Department has concluded an analysis and has determined that a civil penalty is warranted for a serious bodily injury. The 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 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, August 31, 2021, 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 in the amount of $10,000.

A copy of the LIC 421D was given to the Administrator, Jeff Sumabat and originals were signed on file.

Exit interview conducted. A copy of the report issued. Appeal Rights provided. The Administrator, Jeff Sumabat's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021

LIC809 (FAS) - (06/04)

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