415600808-2-10-2021-14-AS-KHOS-BYJMFK-20210224083428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600808
Report Date: 02/10/2021
Date Signed: 02/10/2021 02:10:08 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
04/01/2020 and conducted by Evaluator Shabana Buksh

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200401162242

FACILITY NAME:	ALWAYS TLC		FACILITY NUMBER:	415600808
ADMINISTRATOR:	CONSUNJI, TOMAS		FACILITY TYPE:	740
ADDRESS:	226 SANDPIPER COURT		TELEPHONE:	(650) 345-1441
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	6	CENSUS: 4	DATE:	02/10/2021
		UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Tomas Consunji		TIME COMPLETED:	01:56 PM

ALLEGATION(S):

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Resident sustained injuries while in care

INVESTIGATION FINDINGS:

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On 02/10/2021, Licensing Program Analyst (LPA) Buksh, conducted a tele - complaint investigation with Administrator, Tomas Consunji to deliver and discuss the final findings of the above allegation.
On 04/01/2020, the Department received a complaint alleging that Resident sustained injuries while in care. The initial facility investigation was conducted on 04/13/2020.
Regarding the above allegation, investigation was conducted by the Department, which included review of statement received and pertinent documents such as staffs' medical training records, staffs' Hoyer Lift training records, residents' physician's report, resident's medication administration records (MAR) and photographs of Resident (R1)s injuries. On May 5, 2020, LPA interviewed Staff(S1) regarding the above allegation. S1 stated there is one resident in particular who needs assistance with transfers, so using a Hoyer Lift is necessary. S1 stated, R1 grabbed onto the Hoyer Lift chain while S1 was transferring R1. R1 held onto the Hoyer Lift chain which caused R1 to sustain bruising on the forehead. S1 stated, R1’s forehead had a little red spot but no bruising. S1 admitted to using the Hoyer Lift alone without a 2nd staff to help assist. S3 stated it is required to use 2 staff when using the Hoyer Lift.

Continues on next page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021

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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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
04/01/2020 and conducted by Evaluator Shabana Buksh

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200401162242

FACILITY NAME:	ALWAYS TLC		FACILITY NUMBER:	415600808
ADMINISTRATOR:	CONSUNJI, TOMAS		FACILITY TYPE:	740
ADDRESS:	226 SANDPIPER COURT		TELEPHONE:	(650) 345-1441
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	6	CENSUS: 4	DATE:	02/10/2021
		UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Tomas Consunji		TIME COMPLETED:	01:56 PM

ALLEGATION(S):

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Facility did not report resident's injuries to responsible party
Facility staff failed to administer medication to resident as prescribed.

INVESTIGATION FINDINGS:

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On 02/08/2021, Licensing Program Analyst (LPA) Buksh, conducted a video tele - complaint investigation with Administrator, Tomas Consunji. LPA was given a virtual video tour of the facility. LPA discussed the following findings of the above allegation with the Administrator. On 04/01/2020, the Department received a complaint alleging that facility did not report resident's injuries to responsible party and facility staff failed to administer medication to resident as prescribed. The initial facility investigation was conducted on 04/13/2020. The department’s investigation of this complaint includes review of resident’s medical records, facility and other miscellaneous records, statements and interviews with staff and other possible witnesses.
Regarding allegation that facility did not report resident-1’s (R1) injuries to responsible party (RP). Complainant stated R1 had sustained 2 injuries on different occasions. Complainant’s primary concern is that the facility did not notify R1’s RP in a timely manner. LPA interviewed Administrator, Tom Consunji. Tom stated the incident occurred in the evening on Monday, March 30, 2020. Tom stated he notified R1’s RP around noon the following day. LPA interviewed R1’s RP. RP was upset that the facility did not report the incident right away. RP stated the facility called 15 hours later and notified RP about the incident. Based on the investigation, facility did report the incident to the RP but was not immediately therefore the allegation was UNSUBSTANTIATED.

Continues on next page (LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021

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-20200401162242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
	VISIT DATE: 02/10/2021

NARRATIVE

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Continues..

Regarding the allegation, facility staff failed to administer medication to resident as prescribe. Based on investigation conducted by the Department, which includes staff’s medication training records, statement received, and residents’ medication administration record.

LPA interview Complainant, regarding the above allegation. Complainant stated the facility has a lot of turnovers and that staff is sloppy when it comes to administering medication to residents. Complainant stated the staff would adjust medication without notifying resident’s physician. LPA interviewed Administrator, Thomas Consunji, regarding staff medication training. Thomas stated there is only one staff that is trained to help assist residents with their medication. LPA reviewed Staff-2’s (S2) medication training records. The medication training verification record that was provided by Administrator indicated that S2 completed 8 hours of training in 2018. LPA interviewed Staff-2 (S2) regarding medication training. S2 stated, S2 is the only staff that is trained to assist residents with medication. When S2 is not scheduled to work the Administrator is at the facility to help assist residents with their medication.

The Department has investigated the complaint. Although the allegation may have happened or is valid, therefore the allegation is deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20200401162242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/10/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/11/2021 Section Cited CCR 87411(d)	1 2 3 4 5 6 7	87411 Personnel Requirements - General (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance.	1 2 3 4 5 6 7	Administrator agrees to provide training to staff on assisting residents using Hoyer Life for transfer. Agrees to develop a written plan of correction (POC) describing how facility shall ensure compliance with Regulation Title 22 -87411(d) and shall describe facility plan how similar incident related to violation will be prevented in the future for health and safety of residents. POC shall be received in licensing office by fax and/or mail by due date. Failure to meet POC due date may result in a civil penalty of $100 or more per day.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and record reviews, Licesee didn't give staff training on Hoyer lift resulting in sustaining injuries to R1 during transfer which posed an immediate Safety risk to client in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 14-AS-20200401162242

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
	VISIT DATE: 02/10/2021

NARRATIVE

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Continues..

LPA interviewed Administrator regarding the Hoyer Lift training that was provided for staff. Administrator stated, “the only formal Hoyer Lift operational training we did was from the supplier, Apria Healthcare, when they delivered the lift in 2018.” Administrator stated, “I have no record of exactly when that was but after the deliver and training, we did not use it on the resident until we had practiced and tried it out on each other, me included.”

LPA interviewed 2 staff (S1 & S3), 2 out of 2 staff acknowledged that the injury resident sustain occurred during the transfer using the hoyer lift. Staff is not trained to use Hoyer Lift, which caused R1 to sustain head injury. If there were two staff assisting R1 with Hoyer Lift, it’s likely that injury could have been avoided. Therefore, the allegation was SUBSTANTIATED. Deficiency was cited per CA Code of Regulations Title 22-refer to the 9099d. Report was emailed to Administrator for review and signature. Appeal Rights served.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana Buksh	TELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2021

LIC9099 (FAS) - (06/04)

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