415600257-1-4-2023-14-AS-KHOS-CNDSAA-20230124124201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600257
Report Date: 01/04/2023
Date Signed: 01/04/2023 12:43:24 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
12/29/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221229093304

FACILITY NAME:	SUNVALLEY CHATEAU PACIFICA		FACILITY NUMBER:	415600257
ADMINISTRATOR:	CHRISTIAN TOPIRCEANU		FACILITY TYPE:	740
ADDRESS:	689 LADERA WAY		TELEPHONE:	(650) 355-8948
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY:	16	CENSUS: 11	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Serena Brissett		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff failed to isolate COVID-19 positive resident from other residents
Staff are not taking precautions for COVID-19

INVESTIGATION FINDINGS:

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On 1/4/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint inspection. LPA met with caregiver, Serena Brissett who was wearing face shield, gloves, gown and N95 mask. LPA explained the purpose of the visit and reviewed the allegations.

After the entrance, LPA was provided a tour of the facility by the caregiver who is designated to care for positive COVID-19 residents. LPA observed 3 caregivers and all of them were wearing proper PPEs and they were able to articulate the proper donning and doffing protocol including hand hygiene techniques. LPA observed positive residents were in their rooms with their doors closed. The facility has designated bathrooms with proper PPE supplies set-up inside the bathrooms, hand washing signs are posted by the sinks, closed lid garbage cans, liquid soap and paper towels were observed.

Regarding to allegation of- staff failed to isolate COVID-19 positive resident from other residents, the reporting party stated that a resident who tested positive was in his/her room coughing with the door opened facing the living room while other residents were participating in activities.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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-20221229093304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNVALLEY CHATEAU PACIFICA	FACILITY NUMBER: 415600257
	VISIT DATE: 01/04/2023

NARRATIVE

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Facility staff denied the allegation and stated that it could be a misunderstanding as before they discovered any positive cases, there was a resident who was coughing in his/her room and the door was opened facing the living room where other residents were having activities. After they noticed the coughing, they reported it to the administrator and facility conducted testing right away. After the positive testing results were noted, the facility proceeded with the following actions including but not limiting to: cancelled group activities, placed residents on isolation with doors closed, modified meal and visitation services, set up PPE supplies in the bathrooms, designated bathrooms for positive residents, assigned designated staff to care for positive residents, co-horted residents, etc.

LPA interviewed 4 out of 5 residents and they stated that staff applies proper PPE while providing care and their doors are closed excepted for 1 resident who reported of having the preference of leaving the door a little open. LPA observed there is another room around that area and it is also being occupied by another positive resident.

Based on observation, and interviews during the course of investigation, this allegation is deemed to be unsubstantiated.

Regarding to allegation of- staff are not taking precautions for COVID-19, the reporting party stated that initially staff was not wearing proper PPE and PPE supplies were not available then reporting party observed staff started wearing masks, gloves and plastic aprons (gowns) but staff was not following the proper donning and doffing protocol and proper hand hygiene techniques.

During the investigation, LPA observed the designated staff properly completing the donning and doffing and hand washing techniques before and after providing care to positive residents and the staff who was not assigned to care for the positive residents was able to articulate the steps of proper hand-washing, donning and doffing protocols.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20221229093304

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUNVALLEY CHATEAU PACIFICA	FACILITY NUMBER: 415600257
	VISIT DATE: 01/04/2023

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	Based on observation and interviews, this allegation is deemed to be unsubstantiated. Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with caregiver, Serena Brissett. A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

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