415600808-11-8-2022-14-AS-CSMH-CLHVN6-20221125153438

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600808
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:39:16 AM

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
08/17/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220817140116

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: 3	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Adoracion Mores		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Facility retained a resident who needed a higher level of care
Resident was left in soiled clothing for extended period of time
Facility is malodorous

INVESTIGATION FINDINGS:

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On 11/8/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced to deliver the investigation findings for complaint number 14-AS-20220817140116. LPA met with caregiver, Adoracion Mores and spoke to the administrator on the phone, and explained the purpose of the visit.

Regarding to facility retained a resident who needed a higher level of care, the reporting party stated that the facility was probably capable of caring for residents with early stages of Dementia but not late stages such as resident #1 (R1).

As part of the investigation, LPA interviewed the administrator who denied the allegation and stated the facility conducts a preadmission process to determine admission.

Concerning to R1, the administrator stated that R1 exhibited challenging behaviors after R1's admission that was not previously disclosed by R1's during the pre-admission process. When the administrator realized that the facility required a different level of care that the facility is capable of providing, the administrator contacted R1's responsible party to seek for other placement and scheduled additional staffing to accommodate R1 until new placement is identified.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

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 5

Control Number 14-AS-20220817140116

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: ALWAYS TLC	FACILITY NUMBER: 415600808
	VISIT DATE: 11/08/2022

NARRATIVE

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In addition, the administrator stated that facility staff is trained and educated on caring for residents with diagnosis of Dementia. However, the administrator was not able to provide any training records. This deficiency will be cited on LIC809 and LIC809D under case management.

LPA also interviewed R1's responsible party who validated that when the facility realized that they were not capable of providing the level of care that R1 required, the facility contacted the responsible party to seek for other placement and eventually, R1 was transferred to the acute hospital due to a change of health condition where R1 was discharged to a higher level of care.

Based on documents provided, the LIC 602A (Physician's Order) and the LIC 603A (Resident Appraisal), it did not indicate R1 has current and/or history of challenging behaviors and both documents were completed prior to R1's admission.

Base on record review and interviews during the course of investigation, this allegation is deemed to be unsubstantiated as the facility was not informed of R1's challenging behaviors prior to R1's admission and when the facility learned about these behaviors, the administrator contacted the responsible party to seek for other placement.

Regarding to allegation of resident was left in soiled clothing for extended period of time, the reporting party stated that whenever the responsible party visited R1, R1 smelled like urine, and R1 was left in soiled diapers for an extended period of time.

As part of the investigation, LPA interviewed the administrator who acknowledged the above allegation. However, the administrator stated that staff attempted to clean R1 multiple times a day but with no success due to R1's refusals and aggression behaviors toward facility staff.

LPA also interviewed facility staff members who reported that they attempted to provide Activities Of Daily Living (ADLs) to R1 and attempted to clean R1's room but it was very difficult due to R1's behaviors.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 14-AS-20220817140116

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: ALWAYS TLC	FACILITY NUMBER: 415600808
	VISIT DATE: 11/08/2022

NARRATIVE

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Furthermore, LPA interviewed resident #2 (R2) who stated that R1 needed a lot of help from staff but when staff attempted to help R1, R1 became combative and the facility had an extra staff to help R1.

Base on observation, and interviews during the course of investigation, this allegation is unsubstantiated, no neglect was observed.

Regarding to the allegation of facility is malodorous, the reporting party stated that when the responsible party visited R1, the responsible party smelled urine and feces in R1's room.

As part of the investigation, LPA interviewed the administrator who acknowledged that R1's room had an unpleasant smell as R1 urinated on the floor, and had bowel movements in the closet on a daily basis. Facility staff did the best they could to clean the room and get rid of the odor.

LPA interviewed R2 who stated that facility staff do a good job with cleaning and the facility is always cleaned.

During the investigation, LPA toured the facility and resident's room and observed it to be cleaned, odorless and tidy.

Base on observations and interviews during the course of investigation, this allegation is 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 the administrator.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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 Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220817140116

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: 3	DATE:	11/08/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Adoracion Mores		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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Facility accepted resident without a proper pre-appraisal

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 14-AS-20220817140116

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: ALWAYS TLC	FACILITY NUMBER: 415600808
	VISIT DATE: 11/08/2022

NARRATIVE

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In addition, the administrator provided a copy of R1's appraisal that was completed on 6/1/2022 (R1 was admitted on 6/4/2022) which revealed R1 has a diagnosis of Dementia but R1's challenging behaviors were not mentioned. Furthermore, the facility provided a copy of R1's Physician's Report which also did not indicate R1's challenging behaviors.

After the investigation, the above allegation is deemed to be unfounded as the administrator completed the pre-appraisal prior to R1's admission.

Based on record review, and interview during the course of the investigation, this complaint is deemed to be UNFOUNDED, meaning that these allegations were false, could not have happened and/or is without a reasonable basis as during the investigation.

This report is reviewed with the administrator.

A copy is provided.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5