415601015-6-19-2024-14-AS-ACON-D7GL8C-20240724083140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601015
Report Date: 06/19/2024
Date Signed: 06/19/2024 05:53:25 PM

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
06/17/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240617151929

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: 130	DATE:	06/19/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Business Office Manager, Arno Monteiro		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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Staff mismanaged resident medication

INVESTIGATION FINDINGS:

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On June 19, 2024, Licensing Program Analyst (LPA), Murial Han conducted a 10-day complaint visit. LPA met with the Business Office Manager upon arrival and explained the purpose of the visit. Momentarily, the Memory Care Coordinator, Anne Aquino arrived and assisted with the complaint investigation.

As part of the investigation, LPA interviewed facility staff, resident-in-question (R1) and reviewed documents.

Regarding to allegation of staff mismanaged resident medication, the reporting party stated that in October 2023, R1 received 2 shots of flu and COVID-19 vaccines on the same day and the second part of this allegation, the reporting party stated that R1 recently found a medication/pill on the floor in his/her room and it was returned to one of the Medication Technicians (Med Tech) on the same day and this has happened in the past. In addition, the reporting party stated that there should not be any mediation in R1's room as the facility was managing R1's medication.

According to the Med Tech (S1) who recalled incident and stated that the medication should not be found in R1's room and they are supposed to make sure resident takes their medication.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

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-20240617151929

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: 06/19/2024

NARRATIVE

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LPA interviewed the facility coordinator who stated that it was discovered by staff #2 (S2) that the medication found in R1's room did not belong to R1 and this was communicated to R1's responsible party.

LPA interviewed R1 who was not able to recall the incident and stated he/she gets medications from staff twice a day- morning and night.

Based on facility's Program Description under Medication Support, it stated that medication will be centrally stored and monitored by designated and trained community staff unless arrangements have been made with the administrator and R1 and R1's responsible party did not have any arrangements with the administrator to keep his/her own medication in his/her room.

Based on R1's services and needs plan, R1 requires complete assistance with all medication administration by the facility. Therefore, there should not be any medication left unattended in R1's room.

Based on interviews, and record reviews, this allegation is substantiated as the facility did not ensure centrally stored medication was inaccessible to residents in care.

In regards to R1 was administered 2 shots of flu and COVID-19 vaccines on the same day as the 2nd doses were administered without a consent.

Based on the documents provided, the pervious Resident Service Director acknowledged that R1 was not supposed to receive another doses of the vaccine and the mistake was due to lack of facility staff present when R1 was being vaccinated. The previous Resident Service Director stated he/she and other staff were assisting the 3rd party Pharmacist with the vaccine clinic to make sure residents have their proper paperwork and consents for receiving the vaccines and toward the end of the day, the staff who was assisting the Pharmacist left to assist another unit as no one was waiting to be vaccinated. Subsequently, R1 went to the vaccine clinic and was vaccinated by the Pharmacist who did not check the consent.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20240617151929

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: 06/19/2024

NARRATIVE

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LPA interviewed the facility coordinator who validated the information that was provided by the previous Resident Service Director.

After the investigation, this allegation is substantiated as the facility did not provide supervision while R1 was being vaccinated.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these 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.

Report was discussed with Memory Care Coordinator and Appeal Rights provided

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20240617151929

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: 06/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/20/2024 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure centrally stored medication is inaccessible to residents, and the plan shall include staff education. The administrator will submit a copy of the plan to CCL by 6/20/2024.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on interviews and record review, R1's medication shall be centrally stored and inaccessible to R1, however, R1 found medication in his/her room which posed an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14
Type A 06/20/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services..(f) Basic services shall at a minimum include: (1) Care and supervision.. this requirement is not met as evidenced by based on interviews and record review, there was no	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to prevent this from happening again and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 6/20/2024.
	8 9 10 11 12 13 14	facility staff present providing supervision to ensure consent was obtained prior to R1 receiving 2nd doses of Flu and COVID-19 vaccines which posed an immediate health and safety risks resident in care.	8 9 10 11 12 13 14

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024

LIC9099 (FAS) - (06/04)

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