415601015-1-14-2025-14-AS-ACON-DE2NUZ-20250219094711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601015
Report Date: 01/14/2025
Date Signed: 01/14/2025 11:43:05 AM

Unsubstantiated

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
11/27/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20241127162037

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 seek medical attention for resident in a timely manner resulting in a questionable death
Staff did not keep the residents authorized person informed regarding the resident's hospitalization

INVESTIGATION FINDINGS:

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On January 14, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the 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 seek medical attention for resident in a timely manner resulting in a questionable death, the reporting party stated that on 11/13/2024, the facility did not complete a safety check on resident #1 (R1) during change of shift around 6:30 am resulting R1 being on the floor for hours instead of receiving immediate medical attention.

As part of the investigation. LPA interviewed the memory care director who stated that R1 did not require any assistance with medication management, activities of daily living, and etc. Therefore, the facility was only providing daily safety checks on each shift at varies times during the shift. The memory care director stated that the safety checks were not scheduled. In addition, the memory care director stated that the facility provided a call pendent for R1 to use for assistance but R1 was often found not utilizing it.

Unsubstantiated

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)

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Control Number 14-AS-20241127162037

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 R1's evaluation/service needs and plan, it indicated that R1 did not required assistance for grooming, eating, walking, dressing, etc.

After the investigation, this allegation is deemed to be unsubstantiated as there was no proof indicating the duration of R1 on the floor and there was no document indicating there was an agreement between the facility and the responsible party that the safety checks shall be completed at the beginning of each shift.

Regarding to the allegation of - staff did not keep the residents authorized person informed regarding the resident's hospitalization, the reporting party stated that the facility informed him/her that R1 was transferred to the South San Francisco Kaiser due to a fall and when he/she called South San Francisco Kaiser and another Kaiser, he/she was told that R1 was not there. Subsequently, the responsible party called the facility and spoke to staff #1 (S1) who stated that he/she would get more information and call the responsible party back. However, S1 never called the responsible party instead staff #2(S2) called the responsible and by that time, the responsible party had already got a call from the hospital where R1 was transferred to.

As part of the investigation, LPA interviewed the memory care director, and S1.

According to the memory care director, during the transfer, the paramedics informed S1 that R1 would be transferred to Kaiser South San Francisco and the facility was not aware that R1 was being brought to another hospital until they were informed by the responsible party. The memory care director stated that S1 did not call the responsible party back because the responsible party called S1 when the shift was ending, therefore, S1 endorsed it to the incoming shift med tech (S2) to continue to follow up and called the responsible party back when additional information was obtained.

LPA interviewed S1 who also reported that he/she was told by the paramedics that R1 would be transferred to Kaiser South San Francisco and stated that when the responsible party called, the shift was ending so he/she endorsed it to the incoming staff to follow up.

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)

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Control Number 14-AS-20241127162037

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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After the investigation, this allegation is deemed to be unsubstantiated as the facility was unaware of R1's final destination which was decided by the paramedics after R1 had left the facility. However, during the investigation, the director acknowledged that staff did not get R1's vitals and report the result back to the responsible party as requested by the responsible party. This observation will be cited on Case Management visit under LIC809 and LIC809D.

Although the above allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the memory care director. A copy is 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)

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