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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600755
Report Date: 10/21/2022
Date Signed: 10/21/2022 05:40:20 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
07/07/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220707132155
FACILITY NAME:J AND V FAMILY CARE HOMEFACILITY NUMBER:
415600755
ADMINISTRATOR:ANDAYA, JULITA DFACILITY TYPE:
740
ADDRESS:329 SAN PABLO AVENUETELEPHONE:
(650) 952-5231
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: 5DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Catalina Dela CruzTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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- Staff provided incorrect POLST paperwork to paramedics
INVESTIGATION FINDINGS:
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Based on information reported by and obtained from facility staff, San Mateo County Sheriff and Fire Dept. reports, this allegation is substantiated. The preponderance of evidence standard has been met.

Resident #5 passed away on 6/21/22, according to Incident and Death Reports submitted to CCLD on 6/27/22. Additional information was provided by administrator by phone on 6/28/22 and in writing on 7/8/22. When paramedics arrived, staff provided them with the client folder of another resident in error, which included a POLST that specified "Do Not Attempt Resuscitation/DNR (Allow Natural Death)." According to administrator, staff was nervous and uneasy. R5 did not have a DNR on file.

Deficiency of the CA Code of Regulations, Title 22 is cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
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-20220707132155
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: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited
CCR
87411(a)
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PERSONNEL REQUIREMENTS - GENERAL
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement was not met, as staff referenced on LIC812 failed to provide EMTs with acccurate client information
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Staff to receive training specific to emergency responses from CCLD approved vendor .
Proof of training to be submitted to CCLD within 7 days of training.
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on 6/21/22 during medical emergency of R5. Licensee failed to ensure that staff were competent to meet resident's needs, which posed an immediate health, safety and personal rights risk to clients in care. Because this error may have contributed to R5 death, LIC421M issued to assess immediate $500 civil penalty.
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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: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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
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
07/07/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220707132155

FACILITY NAME:J AND V FAMILY CARE HOMEFACILITY NUMBER:
415600755
ADMINISTRATOR:ANDAYA, JULITA DFACILITY TYPE:
740
ADDRESS:329 SAN PABLO AVENUETELEPHONE:
(650) 952-5231
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY:6CENSUS: DATE:
10/21/2022
UNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Catalina Dela CruzTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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- Questionable death
INVESTIGATION FINDINGS:
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Based on information reported by and obtained from facility staff, San Mateo County Sheriff and Fire Dept. reports, and Death Certificate, this allegation is determined to be unsubstantiated.

On 6/21/22, when Resident #5 passed away, staff observed that he was breathing heavily and non-responsive. Staff called administrator and 9-1-1. They performed CPR as directed by 9-1-1 dispatcher. Five minutes later, County Sheriffs and Fire Dept. paramedics arrived and observed that R5 was without a pulse. A binder was observed in the bedroom where R5 was; it contained personal and medical history information including POLST for another resident #1. Based on the DNR observed in the bedroom where R5 was found, fire dept. paramedics did not start CPR and cancelled EMS. The immediate cause of death per Death Certificate is acute renal failure.
According to Incident and Death Reports submitted to CCLD on 6/27/22, R5 was very weak, sleeping more than usual, and had poor appetite. R5 was diagnosed with dementia, hypertension and diabetes. In addition, hospice services were being considered by client's family.

Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022
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