415601015-12-27-2023-14-AS-KHOS-CZALNF-20240108075415

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601015
Report Date: 12/27/2023
Date Signed: 12/27/2023 02:15:57 PM

Substantiated

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
10/30/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231030105833

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: 125	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Sylvia Chu		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Facility did not follow residents care plan regarding alcohol

INVESTIGATION FINDINGS:

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On December 27, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings to complaint number 14-AS-20231030105833. LPA met with the administrator and explained the purpose of today's visit.

Regarding to allegation of facility did not follow resident's care plan regarding to alcohol, the reporting party reported that upon admission, it was stated in resident #1 (R1)'s care that R1 shouldn't be served alcohol and facility continued to give R1 alcohol despite being reminded by family.

As part of the investigation, LPA interviewed administrator, facility director, staff, and reviewed documents.

According to the administrator, facility director and staff, R1's was served a minimal amount of alcohol during facility's daily Happy Hour event until a few months ago when they obtained an order from R1's physician stating that R1 was not supposed to have alcohol.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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 7

Control Number 14-AS-20231030105833

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: TROUSDALE, THE	FACILITY NUMBER: 415601015
	VISIT DATE: 12/27/2023

NARRATIVE

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Based on the documents provided by the facility, R1's admission physician's report (LIC 602) dated on August 2, 2022 indicated that R1 was not supposed to have alcohol and an additional physician's order (LIC602) dated on August 11, 2023, reiterated that R1 was not permitted to have alcohol consumption due to current diagnosis and current medication regime.

After the investigation, this allegation is deemed to be substantiated as per R1's physician's reported dated on August 2, 2022 and August 11, 2023 that R1 was not supposed to have alcohol. However, the facility failed to follow the physician's order dated on August 2, 2022 and served R1 alcohol.

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.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 14-AS-20231030105833

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: TROUSDALE, THE	FACILITY NUMBER: 415601015
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/28/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations,..	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure facility is following the physician's order for all residents and the plan shall include staff in-services.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility did not follow R1's physician's order upon admission as indicated on the LIC602 "no use of Alcohol" and served R1 alcohol until a 2nd physician's order of no alcohol was obtained which posed an immediately health risk to resident in care.	8 9 10 11 12 13 14	The administrator/licensee will provide a copy of the plan and estimated time of in-service completion to CCL by 12/28/2023.
	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: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
10/30/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231030105833

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: 125	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Sylvia Chu		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Resident acquired infection due to neglect

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 14-AS-20231030105833

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: TROUSDALE, THE	FACILITY NUMBER: 415601015
	VISIT DATE: 12/27/2023

NARRATIVE

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According to facility director, R1 did not required assistance for bathing/showering until September 2023 when the facility received an order from R1's physician to treat R1's foot condition. After obtaining the physician's order, facility updated R1's functional evaluation and started providing assistance to R1 for bathing/showering.

In addition, the facility director reported that there were many days that R1 did not want to take a shower and when that happened, it was re-offered to him/her again on the same day at a later time.

Based on the documents provided by the facility, LPA observed facility was providing treatment to R1's foot per physician's order and facility staff assisted R1 for showers and when R1 refused, it would be offered again on a different shift.

After the investigation, this allegation is deemed to be unsubstantiated as R1 stated that his/her foot condition has been a pre-existing condition and facility staff has been providing showers to R1 on a weekly basis. In addition, the facility provided activities of daily living based on the functional evaluation outcomes. Furthermore when R1 refused to take a bath/shower, facility staff encouraged and offered it again.

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.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

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
10/30/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231030105833

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: 125	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Sylvia Chu		TIME COMPLETED:	02:25 PM

ALLEGATION(S):

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Residents family did not give consent for resident to transfer apartment
Facility failed to safeguard residents property

INVESTIGATION FINDINGS:

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On December 27, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the investigation findings to complaint number 14-AS-20231030105833. LPA met with The administrator and explained the purpose of today's visit.

Regarding to allegation of residents family did not give consent for resident to transfer apartment, the reporting party stated that facility moved resident #1 (R1) into a different apartment, rooming with a female resident without the responsible party's consent.

As part of the investigation, LPA toured R1's apartment, interviewed R1, and the administrator.

During the visit on 11/3/2023, administrator denied the allegation and provided a tour of R1's apartment where LPA observed R1's name was posted by the door and a welcome sign with R1's name on it.

Based on the documents provided by the facility, they revealed that R1 remained in the same apartment number upon admission.

LPA interviewed R1 who stated that the facility did not move him/her into another apartment but he/she preferred to spend the night at another resident's apartment.

After the investigation, this allegation is deemed to be unfounded as R1 was never transferred to another apartment.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 14-AS-20231030105833

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: TROUSDALE, THE	FACILITY NUMBER: 415601015
	VISIT DATE: 12/27/2023

NARRATIVE

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Regarding to the allegation of - facility failed to safeguard resident's property, the reporting party stated that facility destroyed R1's recliner that was brought from home.

As part of the investigation, LPA interviewed the administrator, toured R1's apartment and reviewed documentation.

LPA interviewed the administrator who acknowledged that the facility discarded R1's recliner because it was infested with bed bugs and they were instructed by the infection control company to get rid of it. However, the facility communicated to the responsible party that R1's account will be credited when a new recliner is purchased.

Based on the documentation provided, it stated that facility has agreed to reimburse the responsible party when a new recliner is purchased.

After the investigation, this allegation is deemed to be unfounded.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed with the memory care director and a copy is provided

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 7