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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600734
Report Date: 05/10/2023
Date Signed: 05/12/2023 04:51:21 PM

Substantiated


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
08/17/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220817100625
FACILITY NAME:GONZALES HOMEFACILITY NUMBER:
415600734
ADMINISTRATOR:GONZALES, ROGELIO & PROSPEFACILITY TYPE:
740
ADDRESS:3645 FLEETWOOD DRIVETELEPHONE:
(650) 589-8820
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
05/10/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Randy BandongTIME COMPLETED:
04:35 PM
ALLEGATION(S):
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- Resident developed an unstageable pressure injury while in care
INVESTIGATION FINDINGS:
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 ***This is an amended report correcting an information error***

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings in regards to the investigation of the allegations listed above. LPA met with licensee Randy Bandong and explained the purpose of today's visit.

During the course of the investigation multiple interviews were conducted, resident medical records, letters, facility records, and other pertinent documentes were reviewed in consideration for the investigation findings. R1 developed a pressure injury while in care at the facility that began as unstageable and progressed to a stage 3 pressure injury.

Continued on next page...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2023
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-20220817100625
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: GONZALES HOME
FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
05/13/2023
Section Cited
CCR
87465(a)
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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.
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Licensee shall develop a plan of action in writing describing how the facility will ensure that appropriate care, observation of residents for injuries, and seeking timely medical attention.
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This regulation has not been met as evidenced by: Licensee failed to perform care and supervision to the resident to address the care need of a resident who developed an unstageable pressure injury while in care.

Civil penalties are assessed at $100 x 5 days = $500
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Type A
01/25/2024
Section Cited
CCR
87405(d)1
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87405 Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
(1) Knowledge of the requirements for providing care and supervision appropriate to the residents.
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Licensee shall develop a plan of action in writing describing how the administrator will demonstrate knowledge of this regulation.
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This regulation has not been met as evidenced by: Licensee failed to perform care and supervision to a resident by not addressing the care needs of a resident who developed an unstageable pressure injury while in care.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20220817100625
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: GONZALES HOME
FACILITY NUMBER: 415600734
VISIT DATE: 05/10/2023
NARRATIVE
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Page 2 - LIC9099

Staff noticed that the injury progressively got worse while at the facility and it was only reported to a home health nurse after it had already progressed to a the stage 3 pressure injury. The facility failed to provide timely medical attention to the injury to prevent it from progressing to a stage 3 pressure injury. The allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. This investigation is still under consideration for additional civil penalties.

Civil penalty assessed at $100 a day x 5 days = $500. Civil penalty is attached on the following LIC421IM.

Report is reviewed with care giver Randy Bandong.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3