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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600822
Report Date: 11/14/2022
Date Signed: 11/14/2022 11:45:33 AM

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
08/29/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220829121359
FACILITY NAME:LINCOLN RESIDENCE 653 CARE HOME BY RNSFACILITY NUMBER:
415600822
ADMINISTRATOR:BAUTISTA, ALEXANDERFACILITY TYPE:
740
ADDRESS:653 COMMERCIAL AVENUETELEPHONE:
(650) 952-1941
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Ryan GalangTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident sustained a stage 2 pressure injury in care.
Facility accepted resident with a stage III pressure injury without an exception.
INVESTIGATION FINDINGS:
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On November 14, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Caregiver, Ryan Galang and explained the purpose of the visit.

Regarding the allegation that the resident sustained Stage 2 pressure injuries in care, according to the complainant resident #1 (R1) developed a Stage 2 pressure ulcer on his/her sacrum. During the investigation, LPA collected and reviewed R1’s documents and interviewed staff.

Based on the R1’s medical records, R1 was seen at the hospital on August 9, 2022 and later admitted to the facility on August 10, 2022 with 3 pressure injuries; two on R1’s left calf (inferior and superior) and one on R1’s right calf. Medical records indicate that he had two other sites at risk for pressure ulcers: on the sacrum and on intergluteal cleft. In addition, it was noted on R1’s medical records that the two pressure injuries that were at risk of forming when R1 was seen on August 10, 2022 could be prevented if facility provided R1 with proper pressure injury prevention care treatment. Furthermore, R1’s medical records indicated that R1 was seen by the wound care clinic on August 26, 2022 and was treated for a new sacral ulcer and bilateral lower extremities pressure ulcers. According to interviewed staff, it was acknowledged R1 has two stage 3 pressure injuries on his/her left calf and one stage 3 pressure injury on his/her right calf. Furthermore, the administrator indicated that R1 has one stage 2 pressure injury on his/her sacrum. Although the administrator, indicated that R1 developed the stage 2 sacral ulcer at his/her home, medical records reviewed indicated R1 was seen at the hospital on August 9, 2022 and presented with being at risk of developing a pressure ulcer on the sacrum.

(CONT. TO 9099C)


  
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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 4
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
08/29/2022 and conducted by Evaluator Komal Charitra
COMPLAINT CONTROL NUMBER: 14-AS-20220829121359

FACILITY NAME:LINCOLN RESIDENCE 653 CARE HOME BY RNSFACILITY NUMBER:
415600822
ADMINISTRATOR:BAUTISTA, ALEXANDERFACILITY TYPE:
740
ADDRESS:653 COMMERCIAL AVENUETELEPHONE:
(650) 952-1941
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
11/14/2022
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Ryan GalangTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident lost a significant amount of weight while in care.
INVESTIGATION FINDINGS:
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On November 14, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Caregiver, Ryan Galang and explained the purpose of the visit.

Regarding the allegation that resident lost a significant amount of weight while in care, according to the complainant, Resident #1 (R1) has a lost about 16lbs since being discharged from the hospital since August 10, 2022. During the investigation, LPA interviewed staff and reviewed R1’s files and it was acknowledged that R1 was admitted to the hospital due to congestive heart failure. In addition, it was indicated that R1 is currently on a low salt diet. LPA reviewed R1’s discharge documents and observed that due to R1’s congestive heart failure, R1 needs to limit his/her salt intake which may result in weight loss or assist in maintaining a healthy weight. Although staff interviews indicate R1 lost weight, the discharge documents indicate that R1 will lose weight due to his/her diet.

Therefore, based on the documents reviewed and interviews conducted, the allegation that resident lost a significant amount of weight while in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Caregiver, Ryan Galang and a copy is provided with appeals rights.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
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 4
Control Number 14-AS-20220829121359
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: LINCOLN RESIDENCE 653 CARE HOME BY RNS
FACILITY NUMBER: 415600822
VISIT DATE: 11/14/2022
NARRATIVE
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Nevertheless, the facility could have prevented R1 from sustaining a stage 2 pressure injury on the sacrum, however, the facility failed to provide R1 with appropriate treatment to prevent the pressure injury from further forming. 

Based on the information collected and interviews conducted, it was determined that Resident sustained a stage 2 pressure injury in care. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Regarding the allegation that facility accepted resident with a Stage 3 pressure injury without an exception, according to the complainant, the facility did not obtain an exception prior to admitting the R1 with a Stage 3 pressure injury. During the investigation, LPA reviewed R1’s file and interviewed staff. According to the Administrator, it was indicated that he did not request for an exception because R1 was in the process of getting admitted to hospice, however R1 was not admitted to hospice until 9/3/22, almost a month after being admitted to the facility.

Based on the information collected and interviews conducted, it was determined that facility accepted resident with a 3 pressure injury without an exception. The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Caregiver, Ryan Galang and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20220829121359
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: LINCOLN RESIDENCE 653 CARE HOME BY RNS
FACILITY NUMBER: 415600822
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/21/2022
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code).

Violation of this regulation is evidenced by:
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Facility administrator will have a registered nurse assess the resident and ensure the right care and supervision is provided to residents in care.
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Based on the information collected and interviews conducted, facility failed to provide adequate care and supervision to help prevent R1 from sustaining a Stage 2 pressure injury on the sacrum. In addition, facility failed to provide R1 with appropriate treatment to prevent the pressure injury from further forming.
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Type B
11/21/2022
Section Cited
CCR
87616(a)
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87616 Exceptions for Health Conditions: (a) As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition...

Violation of this regulation is evidenced by:
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Facility administrator to submit acknowledgement of CCR 87616. Facility will contact CCL for an exception prior to admitting resident with a prohibited or restricted health condition.
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Based on the information collected and interviews conducted, R1 was admitted to the facility on August 10, 2022 and according to the administrator, an exception request was not submitted to CCLD because R1 was in the process of getting admitted to hospice, however R1 was not admitted to hospice till 9/3/22.
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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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4