415600223-3-12-2020-14-AS-SYIP-BP6SE3-20200430134802

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600223
Report Date: 03/12/2020
Date Signed: 03/12/2020 07:54:42 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
04/25/2019 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20190425142508

FACILITY NAME:	STERLING COURT		FACILITY NUMBER:	415600223
ADMINISTRATOR:	CHARLES, SARAH ST.		FACILITY TYPE:	740
ADDRESS:	850 NO. EL CAMINO REAL		TELEPHONE:	(650) 344-8200
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	24	CENSUS: 19	DATE:	03/12/2020
		UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Novie Ann Villafuerte		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-- Staff failed to provide adequate supervision resulting in resident falling

-- Resident sustained pressure injury while in care

INVESTIGATION FINDINGS:

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

LPA Jeung reviewed file for former client, who resided in room 121. She moved from independent apartment in this building to licensed assisted living unit on 8/31/18 and was receiving hospice services upon her admission to assisted living. An Unusual Incident Report was submitted to CCLD when client fell on 11/16/18 in her apartment. Staff responded appropriately and called 9-1-1, hospice nurse and responsible party. It cannot be determined at this time if lack of supervision resulted in her fall.

Client was treated by hospice nurses for "superficial" stage 2 pressure injury in January 2019, which is not a prohibited condition. BAsed on documentation observed from hospice agency staff, client received appropriate wound care.

Although these allegations may have occurred or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, it is determined that allegations are unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2020

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 1