415601052-3-22-2022-14-AS-KHOS-CDQHQM-20220422062411

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601052
Report Date: 03/21/2022
Date Signed: 03/22/2022 09:47:32 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/23/2020 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200123121940

FACILITY NAME:	SILVER OAKS		FACILITY NUMBER:	415601052
ADMINISTRATOR:	RUBIO, NANCY		FACILITY TYPE:	740
ADDRESS:	16 COLEMAN PLACE		TELEPHONE:	(707) 592-1157
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	43	CENSUS: 38	DATE:	03/21/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Nancy Rubio		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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- Resident sustained unexplained injuries while in care
- Facility staff failed to meet the resident's hygiene needs
- Facility staff failed to report incident to resident's authorized representative

INVESTIGATION FINDINGS:

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Based on investigation conducted by this Dept., it cannot be proven that client sustained unexplained injuries because staff neglected to provide adequate supervision. Medical records were reviewed, and staff and witnesses were interviewed. Client was admitted to facility on 1/3/20 and reported leg pain to facility staff on 1/4/20. Bruise on client's thigh was observed and assessed on 1/5/20 by staff; client did not complain of pain. On 1/6/20, client went to her day program, as she reportedly had no gait difficulties, no pain, and no SoB. However, due to gait difficulties and SoB observed by day program staff the same day, she was evaluated at hospital emergency room and discharged with no broken bones nor fractures. On 1/7/20, MD prescribed pain relief medication in response to report from facility staff that client complained of leg pain on 1/4/20. Client had a scheduled appointment with her MD on 1/11/20, and X-ray revealed that she had a pelvic fracture, which was noted to be consistent with a fall. Client did not report a fall, nor were staff aware of client falling. MD stated that the fracture may not have been detected by X-ray on 1/6/20.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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-20200123121940

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVER OAKS	FACILITY NUMBER: 415601052
	VISIT DATE: 03/21/2022

NARRATIVE

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During the first week or so of client's admission to facility, staff were unable to brush her hair piece, as client refused to take it off. This was reported in writing to CCLD on 1/8/2020. Appraisals and care plan are maintained and reviewed. Logs for staff to initial when assisting clients with showers and bowel and urine output are also maintained and reviewed. Other than client's early resistance to hygiene assistance, responsible party had no concerns that staff neglected to meet her hygiene needs.

Client complained of leg pain on 1/4/20 and staff observed bruises on client's leg on 1/6/20. However, there is no evidence that staff notified MD, responsible party and administrator until 1/7/20; faxed or scanned notification to MD is dated 1/7/20, with request for pain medication. It cannot be confirmed that staff reported client's complaint of pain prior to 1/7/20.

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

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/23/2020 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200123121940

FACILITY NAME:	SILVER OAKS		FACILITY NUMBER:	415601052
ADMINISTRATOR:	RUBIO, NANCY		FACILITY TYPE:	740
ADDRESS:	16 COLEMAN PLACE		TELEPHONE:	(707) 592-1157
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	43	CENSUS: 38	DATE:	03/21/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Nancy Rubio		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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- Facility failed to seek timely medical attention

INVESTIGATION FINDINGS:

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Based on interviews with staff and witnesses and review of medical records, the preponderance of evidence standard has been met. Therefore, the Dept. has determined the above allegation to be SUBSTANTIATED.

Despite client's complaint of leg pain on 1/4/20, bruise observed by staff on 1/5/20, gait issues observed by staff on 1/6/20, and X-rays taken at hospital on 1/6/20, staff failed to report to client's PCP until 1/7/20. Client was medically evaluated at hospital on 1/6/20 after day program staff observed client with bruising, difficulty walking and shortness of breath, and reported to client's family.

Deficiency of the California Code of Regulations, Title 22, is cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20200123121940

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: SILVER OAKS	FACILITY NUMBER: 415601052
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/21/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/31/2022 Section Cited CCR 87466	1 2 3 4 5 6 7	OBSERVATION OF THE 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, the licensee shall ensure that such changes are documented and brought	1 2 3 4 5 6 7	Plan of correction to be submitted to CCLD BY DUE DATE.
	8 9 10 11 12 13 14	to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met, based on investigation conducted by the Dept. Licensee failed to report pain and bruises to client's MD when staff were aware of client's condition, which posed a potential risk to client's health, safety or personal rights.	8 9 10 11 12 13 14
	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: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4