415601068-11-1-2022-14-AS-CSMH-CKY2BL-20221107161516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601068
Report Date: 11/01/2022
Date Signed: 11/01/2022 11:34:04 AM

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
06/07/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220607085541

FACILITY NAME:	JLA HEALTHCARE SERVICES		FACILITY NUMBER:	415601068
ADMINISTRATOR:	BUSTAMANTE, ELOISA		FACILITY TYPE:	740
ADDRESS:	1012 EL CAMINO REAL		TELEPHONE:	(650) 477-2857
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	0	CENSUS: 0	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Eloisa Bustamante		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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8
9

Facility did not report incident to CCL

INVESTIGATION FINDINGS:

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5
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13

On November 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Administrator, Eloisa Bustamante and explained the purpose of the visit.

Regarding the allegation that facility did not report incident to CCL, according to the reporting party, on April 26, 2022, Resident #1 (R1) fell of his/her hoyer lift onto the floor and was taken to the ER. In addition, the reporting party indicated that on May 18, 2022, R1 was transported to the ER due to seizures that were brought as a result of the fall and passed away two days later.

During the investigation, Administrator was able to provide LPA with a copy of the incident report for the incident that occurred on 4/25/22 and R1’s death report with the fax confirmation sheet indicating it was submitted to CCLD, however Administrator was unable to provide a copy of the incident report for the incident that occurred on 5/18/22. According to the Administrator an internal report was done by the facility and administrator was able to provide LPA a copy of the internal report. Furthermore, an incident report was not submitted to CCLD for the incident that occurred on 5/18/22.

Based on the documents collected and interviews conducted. It was determined that facility did not report incident to CCL. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with appeals rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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 3

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
06/07/2022 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220607085541

FACILITY NAME:	JLA HEALTHCARE SERVICES		FACILITY NUMBER:	415601068
ADMINISTRATOR:	BUSTAMANTE, ELOISA		FACILITY TYPE:	740
ADDRESS:	1012 EL CAMINO REAL		TELEPHONE:	(650) 477-2857
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	0	CENSUS: 0	DATE:	11/01/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Eloisa Bustamante		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable Death

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On November 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Administrator, Eloisa Bustamante and explained the purpose of the visit.

Regarding the allegation of questionable death, according to the reporting party, on April 26, 2022, Resident #1 (R1) died due to Staff #1 (S1) not assisting hospice aide in transferring R1 with a hoyer lift, causing R1 to fall, resulting in R1’s death on May 22, 2022.

During the investigation, the Department collected Resident #1 (R1’s) documentation and conducted interviews. Based on the staff interviewed, although both the facility staff member and hospice aid were assisting R1, they both put each other at fault. In addition, it was indicated R1’s sling was improperly placed causing R1 to fall, hit his/her head and sustain an injury to the back of the head. Based on medical reports reviewed, R1 was transported to the hospital and was diagnosed with subdural hematoma which lead to his/her seizures resulting in R1’s death. In addition, the immediate cause of death listed on R1’s death certificate was subdural hemorrhage with Alzheimer’s disease as a contributing factor.

Based on the documents collected and the interviewes conducted, the above allegation is UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegation is unsubstantiated at this time.

Report is reviewed with Administrator and a copy is provided

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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 3

Control Number 14-AS-20220607085541

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: JLA HEALTHCARE SERVICES	FACILITY NUMBER: 415601068
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/01/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/08/2022 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	87211 Reporting Requirements:(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following...(1)A written report shall be submitted to the licensing agency... within seven days of the occurrence of any of the events specified in (A) through (D) below... Violation of this regulation is evidenced by:	1 2 3 4 5 6 7	Administrator will ensure that all incidents that occur at the facility will be submitted and reported to CCLD by 7 days.
	8 9 10 11 12 13 14	Based on record review, it was found that the facility did internal reporting for an incident that occurred on May 18, 2022, however did not submit an incident report to CCLD.	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: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC9099 (FAS) - (06/04)

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