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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600191
Report Date: 04/08/2022
Date Signed: 04/08/2022 10:11:07 AM

Substantiated


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
02/22/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220222113600
FACILITY NAME:ATRIA DALY CITYFACILITY NUMBER:
415600191
ADMINISTRATOR:AMANDA NORTHFACILITY TYPE:
740
ADDRESS:501 KING DRTELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 62DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Interim Executive Director, Amanda NorthTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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9
Staff did not seek timely medical attention for resident
INVESTIGATION FINDINGS:
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13
On April 8, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Interim Executive Director, Amanda North and explained the purpose of the visit.

Regarding the allegation that staff did not seek timely medical attention for resident, according to the complainant, he/she attempted to call the Interim Executive Director (ED) and the Nurse multiple times due to Resident (R1) being in pain and a decline in R1’s health but did not receive a call back. Based on the interviews conducted, it was indicated that on February 1, 2022, R1 started complaining about being in pain and not being able to walk. In addition, interviewed staff also indicated that R1 seemed weaker, unable to walk, and had a lack of appetite. According to the complainant, from February 2, 2022 through February 9, 2022, several calls were made to the facility in hopes of getting a nurse to reassess R1, but no one returned his/her call. On February 10, 2022, the facility med-tech found R1 semi-unresponsive and called 911 where R1 was then transported to the hospital.

Based on the information collected and interviews conducted. It was determined that staff did not seek timely medical attention for resident. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Amanda North, a copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
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-20220222113600
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 DALY CITY
FACILITY NUMBER: 415600191
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/15/2022
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

Violation of this regulation is not met as evidenced by:
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Facility to conduct in staff training on the importance of documenting and reporting changes in resident's condition. Facility to provide CCLD proof of training documentation by 4/15/22.
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Based on interviews conducted, it was acknowledged that Resident (R1) was complaining about being in pain and not being able to walk. In addition, staff acknowledge R1 feeling weaker, having a loss of appetite and not being able to walk. Nevertheless, the failed to develop a plan to provide assistance in obtaining the care R1 needed or to arrange for care appropriate to the conditions and needs of R1.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
02/22/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220222113600

FACILITY NAME:ATRIA DALY CITYFACILITY NUMBER:
415600191
ADMINISTRATOR:AMANDA NORTHFACILITY TYPE:
740
ADDRESS:501 KING DRTELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 62DATE:
04/08/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Interim Executive Director, Amanda NorthTIME COMPLETED:
10:45 AM
ALLEGATION(S):
1
2
3
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5
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9
Resident sustained pressure injuries while in care
INVESTIGATION FINDINGS:
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2
3
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5
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7
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13
On April 8, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Interim Executive Director, Amanda North and explained the purpose of the visit.

Regarding the allegation that resident sustained pressure injuries while in care, according to the complainant, Resident (R1) sustained Stage 2 pressure sores on her back and both heels on her feet at the facility. During the investigation, it was acknowledged that R1 laid in bed most of the time due to R1 feeling weak, and being in pain. However, staff indicated that there was no record of any pressure injuries sustained by R1 during the time at the facility.

Therefore, based on the information collected, and interviews, the allegation that the resident sustained pressure injury(ies) while in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

This report is reviewed and discussed with Amanda North ; a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3