415601059-10-31-2022-14-AS-KHOS-CQCRX4-20230328132403

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601059
Report Date: 10/31/2022
Date Signed: 10/31/2022 06:12:50 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
10/21/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221021150911

FACILITY NAME:	MEADOW GARDENS OF MENLO PARK		FACILITY NUMBER:	415601059
ADMINISTRATOR:	LI, MICHAEL		FACILITY TYPE:	740
ADDRESS:	800 ROBLE AVENUE		TELEPHONE:	(650) 322-4100
CITY:	MENLO PARK	STATE: CA	ZIP CODE:	94025
CAPACITY:	45	CENSUS: 12	DATE:	10/31/2022
		UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Siobhan Surraco		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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- Staff on duty not adequately trained on the facility's emergency operation procedures
- Facility alarm is outdated/defective
- Staff on duty is not sufficient in numbers, qualifications, and/or competency to meet the needs of residents in care
- Staff did not report a facility emergency in a timely manner

INVESTIGATION FINDINGS:

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LPA Jeung discussed allegations with administrator. She recounted the events of 10/16/22, when an agency staff was on duty with a facility NOC staff, and Ms. Surraco was called because an alarm was sounding. The agency staff had not received any training on facility's emergency procedures, and the facility staff was unable to respond appropriately to emergency personnel, either.
Based on information provided by administrator, staff was told to call 9-1-1 because it was assumed that the fire alarm was sounding. Instead, it appears that emergency pull cord in room 112 was pulled and staff on site did not know what the alarm was for. They did not have knowledge about emergency call system, procedures, nor accessing code for entrance door.
During subsequent fire safety inspection on 10/26/22, facility received notice of violations.
Administrator confirms that written report has not been submitted to CCLD for the 9-1-1 call on 10/16/22.

Based on information reported by and obtained from facility staff, Menlo Park Fire Dept.and Ombudsman, these allegations are substantiated. The preponderance of evidence standard has been met.
Deficiencies of the California Code of Regulations, Title 22, are cited on the following pages.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

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-20221021150911

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: MEADOW GARDENS OF MENLO PARK	FACILITY NUMBER: 415601059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/01/2022 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	PERSONNEL REQUIREMENTS - GENERAL Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met, as staff on duty on 10/16/22 could not discern what alarm was sounding and 9-1-1 was called when a resident used the emergency	1 2 3 4 5 6 7	Administrator to ensure that staff are at all times competent to meet the needs of residents in care, including emergency procedures. Plan/proof of correction will be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	call system in the bathroom to summon staff. Licensee failed to ensure that staff were competent to provide services to meet clients' needs, which posed an immediate health, safety and personal rights risk to clients in care.	8 9 10 11 12 13 14
Type A 11/01/2022 Section Cited CCR 87203	1 2 3 4 5 6 7	FIRE SAFETY All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met, as per Menlo Park Fire Dept. Notice of Violations dated 10/26/22. Licensee failed to ensure that facility conforms	1 2 3 4 5 6 7	Administrator to ensure that facility will conform to CA Fire Codes, as per Menlo Park Fire Dept Notice of Violations. Plan/proof of correction to be submitted to CCLD BY DUE DATE
	8 9 10 11 12 13 14	to local and/or state fire regulations, which poses an immediate health and safety risk to clients 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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20221021150911

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: MEADOW GARDENS OF MENLO PARK	FACILITY NUMBER: 415601059
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/07/2022 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	REPORTING REQUIREMENTS Each licensee shall furnish to the licensing agency such reports as the Dept may require, including, but not limited to, the following:(1) A written report shall be submitted ... within 7 days of the occurrence of any of the events specified in (A) through (D) below. This report shall include any incident which threatens	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	the welfare, safety or health of any resident. This requirement is not met, as no written report was submitted to CCLD for the 9-1-1 call on 10/16/22. Licensee failed to ensure that CCLD was notified of possible emergency incident on 10/16/22, which posed a potential health, safety or personal rights risk to clients in care.	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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3