415601015-1-14-2025-14-AS-ACON-DE2NTV-20250219094519

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601015
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:40:30 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
12/12/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20241212164653

FACILITY NAME:	TROUSDALE, THE		FACILITY NUMBER:	415601015
ADMINISTRATOR:	CHU, SYLVIA		FACILITY TYPE:	740
ADDRESS:	1600 TROUSDALE DR		TELEPHONE:	(650) 443-3700
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	140	CENSUS: 105	DATE:	01/14/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Memory Care Director, Anne Aquino		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Staff did not ensure that resident took medication as prescribed
Resident sustained injuries during an witnessed fall due to staff neglect

INVESTIGATION FINDINGS:

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On January 14, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation findings. LPA met with Memory Care Director and LPA explained the purpose of today's visit.

Regarding to the allegation of- staff did not ensure resident took medication as prescribed, the reporting party stated on 11/20/2024 at 7:18PM, resident-in-question (R1) was on the phone with the responsible party who overheard the Medication Technician (Med Tech) did not ensure R1 took the medication by leaving the medication with R1 and left the room. The reporting party stated that this concern has been brought up by the responsible party to the facility director(s) in the past to ensure R1 took the medication before staff leaving the room.

As part of the investigation, LPA interviewed the memory care director and other residents.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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-20241212164653

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TROUSDALE, THE	FACILITY NUMBER: 415601015
	VISIT DATE: 01/14/2025

NARRATIVE

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According to the memory care director, med techs shall ensure residents take their medication(s) before leaving their rooms unless there is a physician's order indicating that staff may leave the medication(s) with the residents.

LPA interviewed resident #2 (R2) who stated that he/she gets medications from staff twice a day. In the morning, facility staff made sure he/she took the medication before leaving the room. However, in the evening, he/she took one pill in the presence of staff and staff would leave the the other pill by the bedside table for him/her to take it before bedtime as the medication causes dizziness.

Based on the documents provided, both R1 and R2 did not have a physician's order to leave medications in their rooms unassisted.

After the investigation, this allegation is deemed to be substantiated as facility staff did not assist residents with their medications.

Regarding to the allegation of- resident sustained injuries during an witnessed fall due to neglect, the reporting party stated that R1 sustained bruising and broken skin from a fall and the shower mat was not placed on the floor by staff may have contributed to the fall.

As part of the investigation, LPA interviewed the memory care director, the administrator and conducted observations.

According to the administrator, the facility provides the non-skid shower mat to the residents and when a resident who is determined to be independent with their Activities of Daily Living including but not limiting to showers, it would be up to the individual resident to place the shower mat on the floor. The administrator acknowledged that the facility did not have a process to ensure the shower mats were placed on the floor for the residents who are independent with showers.

According to the memory care director, the non-skid shower mats were supposed to be on the floor but staff would place them on the grab bars to dry after resident had showered.

In regards to R1's fall, the administrator and the memory care director were aware of the fall and acknowledged that R1's responsible party requested the facility to place the shower mat on the floor at all times to prevent R1 from falling again and they stated that this was verbally communicated to facility staff.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20241212164653

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TROUSDALE, THE	FACILITY NUMBER: 415601015
	VISIT DATE: 01/14/2025

NARRATIVE

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Based on the documents provided by R1's responsible party, LPA observed the shower mat was not placed on the floor on multiple days after R1's fall.

During LPA's visit on 12/20/2024, LPA toured R1 and 9 other resident's rooms and LPA observed the non-skid mats were hanging on the grab bar in R1 and 5 other resident's shower rooms and the mats were all dried.

After the investigation, this allegation is deemed to be substantiated. After R1's fall, the responsible party requested both verbally and in writing for the shower mat to be placed on the floor to prevent R1 from falling again and both the administrator and the memory care director acknowledged that it was endorsed to them. In addition, they stated the facility staff was in-serviced. However, it was observed by R1's responsible party and LPA that the shower mat was on the floor.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the memory care Director, and Appeal Rights provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20241212164653

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: TROUSDALE, THE	FACILITY NUMBER: 415601015
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/15/2025 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care..(a) A plan for incidental medical and dental care shall be developed by each facility... (4)The licensee shall assist residents with self administered medications as needed.	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure facility staff assists residents with their self-administration of medication(s) unless there is a physician's order indicating otherwise. The plan shall
	8 9 10 11 12 13 14	The requirement is not met as evidenced by based on interview, record review and observation, the facility did not assist R1 and R2's medication which poses an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14	include staff training. The administrator will provide a copy of the plan to CCL by 1/15/2025.
Type A 01/15/2025 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not me as evidenced by:	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure facility staff is assisting independent residents with placing the non-skid shower mats on the floor
	8 9 10 11 12 13 14	Based on observation, interview, and record review, the facility did not ensure R1's shower mat was placed on the floor following R1's fall as specifically requested by R1's responsible party for fall prevent which poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	to ensure safety. The plan shall include staff education. The administrator will provide a copy of the plan to CCL by 1/15/2025.

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: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC9099 (FAS) - (06/04)

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