415600868-11-12-2021-14-AS-JMOS-CCQN6L-20220321101117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600868
Report Date: 11/12/2021
Date Signed: 11/12/2021 09:21:32 AM

Unsubstantiated

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
10/19/2020 and conducted by Evaluator Komal Charitra

COMPLAINT CONTROL NUMBER: 14-AS-20201019153643

FACILITY NAME:	PALM ASSISTED LIVING LLC		FACILITY NUMBER:	415600868
ADMINISTRATOR:	RENUKA GANDHI		FACILITY TYPE:	740
ADDRESS:	2818 TIBURON WAY		TELEPHONE:	(650) 777-9044
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	6	CENSUS: 4	DATE:	11/12/2021
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Administrator, Renuka Gandhi		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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-Staff has inadequate record keeping regarding resident
-Staff unlawfully evicted resident

INVESTIGATION FINDINGS:

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On November 12, 2021, Licensing Program Analyst (LPA) Komal Charitra and Licensing Program Manager (LPM) Julio Montes, met with facility administrator, Renuka Gandhi to deliver findings for the above allegations. The investigation had been completed by LPA Garcia.

Regarding the allegation that the resident was unlawfully evicted, On October 18, 2020, R1 was sent to the hospital via ambulance. Information from the complainant indicates that R1 arrived at the hospital, but with no clear reason why R1 was sent to the emergency room. Emergency Department physician called the facility and caregiver responding to the call stating "don't send him back" but did not provide reason why.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

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-20201019153643

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: PALM ASSISTED LIVING LLC	FACILITY NUMBER: 415600868
	VISIT DATE: 11/12/2021

NARRATIVE

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According to the facility administrator, after R1 went to the hospital, the doctor wanted to release him/her back to the facility. However, the administrator wanted the hospital to properly diagnose and treat R1 before his/her release. As result, R1 was examined and actually underwent surgery and was hospitalized from October 18, 2020 to October 24, 2020. Therefore, it appears that all was a misunderstanding.

Regarding the allegation that Staff has inadequate record keeping, according to administrator, Resident 1 (R1) was sent to the ER on October 16, 2020. R1’s documents, including the medication list, were given to the hospital and Emergency Medical Technicians (EMT). On October 18, 2020, R1 was sent the ER a second time and the ER doctor requested for R1’s medication list.

There was some misunderstanding according to the administrator since the medication list was already provided to the hospital on R1’s previous ER visit, and it was also handed to the EMT when R1 was picked up at the facility. According to the administrator, the pharmacy called shortly to request for the medication list, and it was read to the pharmacy over the phone.

According to records review, facility maintains documentation of R1’s medication list on file.
This agency has investigated these allegations. Based on the interviews and information collected, the Department finds that the complaint is UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is no preponderance of evidence to prove the alleged violations occured, therefore the above allegations are unsubstantiated at this time.

The report and findings were discussed with the administrator at the end of visit.

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:	DATE: 11/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021

LIC9099 (FAS) - (06/04)

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