415601039-3-1-2024-14-AS-KHOS-D46MMQ-20240409094416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601039
Report Date: 02/22/2024
Date Signed: 03/01/2024 04:40:26 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
08/04/2023 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230804102303

FACILITY NAME:	CADENCE MILLBRAE		FACILITY NUMBER:	415601039
ADMINISTRATOR:	STROMGREN, KIEL		FACILITY TYPE:	740
ADDRESS:	1201 BROADWAY		TELEPHONE:	(650) 742-9150
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY:	165	CENSUS: 114	DATE:	02/22/2024
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Joan Newman and Marquita Kennedy		TIME COMPLETED:	07:45 PM

ALLEGATION(S):

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- Resident sustained an arm separation while in care
- Resident suffered from dehydration while in care

INVESTIGATION FINDINGS:

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AMENDED REPORT 03/01/2024

Based on investigation conducted by this Department--which included review of facility and medical records and interviews with staff--these allegations are determined to be substantiated. The preponderance of evidence standard has been met.

Client #1 was admitted to facility's memory care unit in January 2022. Care Plan and Service Plan--signed by client's representative--were documented by facility in August 2022; high scores for care needs were noted in the areas of neurogocognitive, mobility/ambulation, toiletting and transferring. It is noted that "resident is dependent on staff for all escort needs, requires frequent supervision and oversight," and frequent status checks. In March 2023, a Care Plan detail was completed by facility staff--but not signed by client's representative; client was noted to require extensive assistance in ambulation, transferring, toileting and moderate supervision due to wandering tendencies. All staff interviewed acknowledged that client was a fall risk. Continued

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

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-20230804102303

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: CADENCE MILLBRAE	FACILITY NUMBER: 415601039
	VISIT DATE: 02/22/2024

NARRATIVE

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According to facility records, several falls were documented--in March 2022, February 2023, April 2023. Client did not sustain any significant injuries as a result of these falls; he was evaluated at the hospital after April 2023 fall and released the same day.
Client was not under direct staff supervision on 5/29/23 when he fell in the common living room of memory care unit and sustained an acute shoulder separation. Client was evaluated and treated at the hospital.

On 6/27/23, client was observed to be unresponsive with low oxygen level. 9-1-1 was called and client was transported to hospital, where tests revealed he was severely dehydrated and significantly hyperglycemic. Client was admitted to ICU with severe sepsis and hypernatremia. Based on staff interviews, client missed 3 meals immediately prior to hospitalization, only one of which was documented. In addition, client was known to be always eager to eat, so his refusal to eat was unusual. Staff failed to accurately document the change in condition. report this to client's family and seek medical advice.

Deficiencies of the California Code of REgulations, Title 22 are cited on a following page, as well as civil penalties of $1000-- $500 for Section 87464 Basic Services and $500 for Section 87466 Observation of Resident. Assessment of additional civil penalties is pending.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230804102303

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: CADENCE MILLBRAE	FACILITY NUMBER: 415601039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 02/23/2024 Section Cited CCR 87464	1 2 3 4 5 6 7	87464 BASIC SERVICES - Basic services shall ... include care and supervision as defined in 87101(c)(3) and Health and Safety Code 1569.2(c), meaning the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with ADLs without which the resident’s physical health, mental health, safety, or welfare would be endangered. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Plan/proof of correction to be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	Based on investigation the licensee failed to ensure adequate supervision of a client who was a fall risk by leaving resident with fall risks alone, which poses immediate health, safety, or personal rights risk to clients in care.	8 9 10 11 12 13 14
Request Denied Type A 02/23/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 OBSERVATION OF RESIDENT - The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes...are observed...such brought to the attention of the resident's physician and the resident's responsible person. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Plan/proof of correction to be sent to CCLD BY DUE DATE
	8 9 10 11 12 13 14	Based on the investigation licensee failed to monitor changes in resident and failed to seek medical attention to address medical needs.	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) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024

LIC9099 (FAS) - (06/04)

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