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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600787
Report Date: 05/06/2022
Date Signed: 05/06/2022 11:46:30 AM

Unfounded


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
05/06/2021 and conducted by Evaluator Jaime Vado
COMPLAINT CONTROL NUMBER: 14-AS-20210506152640
FACILITY NAME:PALM VILLASFACILITY NUMBER:
415600787
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:1931 WOODSIDE ROADTELEPHONE:
(650) 369-3197
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:49CENSUS: 41DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Garry SneperTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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9
Staff failed to address a resident's change in level of care
INVESTIGATION FINDINGS:
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13
On this day at 1000 hours, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced comlaint investigation visit to deliver the findings for complaint allegations received. LPA met with administrator/licensee Garry Sneper and explained purpose of today's visit.

Regarding the allegation above, it was discovered that staff did recognize a change in R1 baseline status before R1 was transported to the hospital for evaluation. Staff noticed that R1 was more tired and quiet than baseline but no other symptoms were a cause for concern as R1 preferred to be in bed. R1 did not have adverse effect due to receiving second dose of COVID vaccine. Medical review was conducted and there was no indication of respiratory issues, or UTI, that would have alerted staff to hold off on the second dose of the vaccine. This allegation is unfounded.

This agency has investigated the complaint alleging that staff failed to address a resident's change in level of care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Report reviewed with administrator.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022
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 2
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
05/06/2021 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210506152640

FACILITY NAME:PALM VILLASFACILITY NUMBER:
415600787
ADMINISTRATOR:SNEPER, GARRYFACILITY TYPE:
740
ADDRESS:1931 WOODSIDE ROADTELEPHONE:
(650) 369-3197
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:49CENSUS: 41DATE:
05/06/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Garry SneperTIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to neglect/lack of care and supervision the resident sustained a questionable death
Resident sustained a prohibited health condition while in care
Staff mishandled a resident's personal belongings while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 1000 hours, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced comlaint investigation visit to deliver the findings for complaint allegations received. LPA met with administrator/licensee Garry Sneper and explained purpose of today's visit.

Regarding the allegations above, it was discovered that R1 had a history of UTI and was taking medication that caused R1 to urinate more frequently and it was noted that staff did recognize a change in the urine and it was reported to physician of R1 and they did notice that R1 was tired and quiet but that was baseline of R1. Upon the death of R1 it was noted that sepsis related to UTI were contributing factors but medical review and interviews showed that there were no indications or changes in the condition of R1 to indicate she was suffering a UTI to alert staff to send R1 to hospital.

Regarding sustained a prohibted helath condition while in care, the facility staff did indicate the changes in urine and change in being more tired and quiet but this did not lead to any susupicions of sepsis or UTI as R1 baseline was similar. Staff did not have any other signs or symptoms to alert that the resident had a prohibited health condition.

Regarding staff mishanlding resdient belongins, LPA could not prove or disprove those items were in place or not at time of admission. The facility indicated that they did keep the belondings of R1the room and did not remove anything and returned everything that was present. Any other items around the room of R1 were left in place for family to retrieve. This is one party's word over another.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is discussed with administrator.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2