415600976-1-31-2023-14-AS-CSMH-CNZTT9-20230213140023

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:46:07 PM

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
05/13/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220513145858

FACILITY NAME:	PENINSULA REFLECTIONS		FACILITY NUMBER:	415600976
ADMINISTRATOR:	ANNA ALLAS		FACILITY TYPE:	740
ADDRESS:	205 COLLINS AVE		TELEPHONE:	(650) 731-4670
CITY:	COLMA	STATE: CA	ZIP CODE:	94014
CAPACITY:	57	CENSUS:	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kathy Nguyen		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Services provided were not conducted so as to continue and promote, to the extent possible, independence and self-direction for resident
- Staff were not sufficient in numbers and competent to provide services to meet resident's needs
- Staff did not ensure changes in resident's physical condition were reported to the resident's physician and/or responsible party.
- Staff did not meet resident's hygiene needs
- Communications from authorized representative have not been answered promptly or appropriately by staff

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an un-announced complaint investigaton visit to deliver the findings for the allegations listed above. LPA spoke to Wellness Director Kathy Nguyen and explained the purpose of today's visit.

During the course of the investiagtion LPA conducted interviews and reviewed pertinent documents relating to the care of R1. According to interviews with staff, they acknowledge that the resident was independent and that they obliged by her requests when they were made. It was said that the resident preferred to either be in her bed, chair, or wheel chair, and so they allowed her to do so. They did not promote her to stay or remain in those items. She chose it on her own.

Continued on next page LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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
05/13/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220513145858

FACILITY NAME:	PENINSULA REFLECTIONS		FACILITY NUMBER:	415600976
ADMINISTRATOR:	ANNA ALLAS		FACILITY TYPE:	740
ADDRESS:	205 COLLINS AVE		TELEPHONE:	(650) 731-4670
CITY:	COLMA	STATE: CA	ZIP CODE:	94014
CAPACITY:	57	CENSUS:	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kathy Nguyen		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Resident sustained a fracture in care

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an un-announced complaint investigaton visit to deliver the findings for the allegations listed above. LPA spoke to Wellness Director Kathy Nguyen and explained the purpose of today's visit.

During the course of the investigation it was discovered by medical records obtained that the resident did sustain a fracture while in care. The resident did fall in the facility and according to staff who witnessed the fall, it was an observable fall after assistance was provided to the resident. The staff person was not close enough to the resident to assist or help the resident from falling as the staff person was too far. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reveiwed with Kathy Nguyen.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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-20220513145858

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: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/01/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.	1 2 3 4 5 6 7	Facility shall submit a written Plan of Correction to ensure compliance with regulation 87411(a). POC to include measures to be implemented to prevent a repeated incident.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and review of documents, R1 had sustained a fracture due to a fall happening in the facility. Staff were present during the fall.	8 9 10 11 12 13 14	POC to be recieved in by due date
	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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 14-AS-20220513145858

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: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
	VISIT DATE: 01/31/2023

NARRATIVE

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Page 2 - LIC9099C

In regards to staffing numbers and staff competency, again the facility indicated that the resident was fairly independent and they assisted and provided the level of care that they were able to meet her everyday needs. There was not an observable lack of competency or staff not being able to meet the resident's needs. LPA could not observe or determine if this allegation is true.

In regards to the facility not reporting changes in the residents physical condition to the responsible party or physician, According to staff they reported any changes to them the best of their ability. In regards to a resident's condition change in physical nature, facility acknowledged that the resident did enter the facility with a specific condition and were aware of what signs to observe. They indicated that if there was any change that needed to be reported that they would report as soon as possible. In the case of the resident being swollen, this was reported to the responsible party as acknowledged by the reporting party. LPA could not determine if this allegation is true.

In regards to not meeting the resident's hygiene needs, LPA discussed and reviewed documents relating to the needs and services of the resident. LPA could not determine of the hygiene needs were not able to be meet. Facility confirms that there was teeth brushing instructions provided and says they were able to assist when needed. In regards to other hygiene needs not being met, such as hand washing, the facility could not determine if soap was not provided. LPA observed soap dispensers at random through out the facility and soap appeared to be in place. LPA could not determine if this allegation is true.

In regards to communications being answered promptly or appropriately by staff, LPA discussed the procedures regarding this and identified that there is a facility phone that families can send text messages to and make calls to that is maintained by staff. Reporting party confirms there had been communications made to her from this number and acknowledged being responded to from this phone. Staff interviewed confirmed that they do respond and message from this phone. Staff are aware that they can report and respond at any time on this phone and do so in a timely manner to the best of their abilities. LPA could not determine if this allegation is true.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. No citations issued. Report is reviewed with Kathy Nguyen.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4