415600874-4-16-2021-14-AS-JMOS-C2GNZN-20210427105433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600874
Report Date: 04/14/2021
Date Signed: 04/16/2021 12:13:15 PM

Substantiated

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
02/26/2020 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200226155821

FACILITY NAME:	BROOKDALE REDWOOD CITY		FACILITY NUMBER:	415600874
ADMINISTRATOR:	NDOMO, GRACE		FACILITY TYPE:	740
ADDRESS:	485 WOODSIDE RD		TELEPHONE:	(650) 366-3900
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	130	CENSUS: 74	DATE:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Rebekah Dilag		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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- Staff left resident on toilet for extended period of time

INVESTIGATION FINDINGS:

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LPA Jeung conducted virtual visit via FaceTime, and reviewed file of former client #1, with assistance from health and wellness director.
Investigation conducted by LPA Jeung included review of facility records and interviews of staff. On 2/2/20, a resident was assisted to the bathroom by a staff, who then left resident on the commode. The staff acknowledged that she forgot to return to assist the client, who managed to get up from the commode an hour and a half later. The following day, the staff apologized to the client. The incident was reported to the health and wellness director and executive director.

This allegation is SUBSTANTIATED, as the preponderance of evidence standard has been met.

***************This report is emailed to Ms. Dalig, to be printed and signed, and returned to LPA via email or fax to 650/266-8841 within 24 hours***********************

Deficiency of the California Code of Regulations, Title 22, is cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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

Control Number 14-AS-20200226155821

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: BROOKDALE REDWOOD CITY	FACILITY NUMBER: 415600874
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/28/2021 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	BASIC SERVICES Basic services shall, at a minimum, include, personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those ADLs, such as dressing, eating, bathing and assistance with taking prescribed medications. This requirement was not met, as staff failed	1 2 3 4 5 6 7	Plan of correction shall be sent to CCLD BY DUE DATE
	8 9 10 11 12 13 14	to assist client with toileting needs on 2/2/20. Licensee failed to ensure that staff assisted client when she was left on the commode, which posed a potential health and safety risk to clients in care. Facility assessment identified client's need for toiletting assistance.	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.

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/26/2020 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20200226155821

FACILITY NAME:	BROOKDALE REDWOOD CITY		FACILITY NUMBER:	415600874
ADMINISTRATOR:	NDOMO, GRACE		FACILITY TYPE:	740
ADDRESS:	485 WOODSIDE RD		TELEPHONE:	(650) 366-3900
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	130	CENSUS: 74	DATE:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Rebekah Dilag		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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- Staff are not responding to resident's calls for assistance in timely manner

- Facility is not adequately staffed to meet needs of residents

INVESTIGATION FINDINGS:

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Complaint alleges that staff are unable to respond timely when clients call for assistance using the facility's emergency call system Tek-Care. Each client bedroom and bathroom has an emergency pull cord which, when activated by a client, sends an alert to caregivers' pagers and CRT at reception desk, showing room of origin and client's name, and time. The reception desk is staffed 24 hours/day. The CRT display remains until staff responds to the room or client, and the receptionist monitors call alerts and walkie talkies caregivers if/when call alert info is not cleared (display removed from CRT). Pagers used by caregivers were in short supply prior to 2/10/20, when facility received an adequate number of pagers. According to executive director, information for period 2/1 - 2/7/20 for assisted living rooms--date, room #, time of call, time of response--cannot be extracted from the system, although historical data can be retrieved for each room number. Without access to review and identify which rooms had long response times and when, it cannot be evaluated if clients experienced long wait times.

-- Continued on next page --

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20200226155821

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: BROOKDALE REDWOOD CITY	FACILITY NUMBER: 415600874
	VISIT DATE: 04/14/2021

NARRATIVE

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According to review of staffing schedule for week of 2/2 - 2/8/2020, there was an average of 7.85 caregivers, LVNs and med aides per day, between 6:30 am and 10:30 pm to meet the needs of 91 residents who required some level of assistance. Additional caregivers were hired in February 2020.

Although the allegations may have occurred or are valid, based on limited information from complainant and facility, there is not enough evidence to prove the alleged violations did or did not occur. Therefore, these allegations are UNSUBSTANTIATED.

********************This visit conducted virtually via FaceTime. This report is emailed to Ms. Dilag, to be printed and signed, and returned to LPA via email or fax to 650/266-8841 within 24 hours***********************

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

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