415601070-5-15-2023-14-AS-KHOS-CSBMTR-20230530095359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 05/15/2023
Date Signed: 05/15/2023 05:20:01 PM

Unsubstantiated

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
09/01/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210901113559

FACILITY NAME:	PENINSULA DEL REY		FACILITY NUMBER:	415601070
ADMINISTRATOR:	CAGULADA, DILLON		FACILITY TYPE:	740
ADDRESS:	165 PIERCE STREET		TELEPHONE:	(650) 992-2100
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	150	CENSUS: 91	DATE:	05/15/2023
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Katherine Tazawa		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff do not provide appropriate care and supervision to the residents while in care
Unqualified staff is providing care and supervision
Staff are performing treatments without doctor's order
Staff are not properly reporting incidents involving residents
Staff mishandle residents medications while in care

INVESTIGATION FINDINGS:

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Based on observations made during initial visit on 9/9/21 by LPAs Han and Charitra, interviews with staff and clients, reviews of facility job descriptions, staff training records, staffing schedules, medication policies and client records, as well as insufficient information provided, these allegations are determined to be unsubstantiated.

As per daily staff assignments for July and August 2021--when there were approximately 60 residents--there were beween 4 to 7 staff working the AM shifts, 3 to 6 staff working PM shifts, and 1 to 5 staff working overnight shifts. It is noted that on 3 nights in August 2021, only 1 or 2 staff worked. It is unknown if any clients were adversely affected.

Training records were reviewed for 3 caregiver/med aides and 2 LVNs, including verification of valid nursing board licensing. Based on records provided, it cannot be determined if caregiver/med aides were up to date on their medication training.

Unsubstantiated

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: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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-20210901113559

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: PENINSULA DEL REY	FACILITY NUMBER: 415601070
	VISIT DATE: 05/15/2023

NARRATIVE

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Continuation--

Based on a partial record review of 2 clients who passed away in May 2021--both of whom were receiving hospice care as well as podiatric care--there was no indication that facility LVN misreported wound status nor provided treatment without MD orders. However, sufficient information--including identities of clients--was not available.

It was observed that staff pre-pour clients' medications not more than 24 hours prior to administration to clients. However, it appears that not the same staff puts the pills in a designated disposable cup and gives the cup to the client, as meds are prepared by staff working a prior shift. According to facility's policies and procedures manual, "all staff will pour the medication each gives." A medication administration record is maintained to document which staff administered what medication to each client, and as per the facility's policies and procedures manual, "the MARs are initialed at the time the medication is placed in the cup." It cannot be determined if the staff who pre-poured the medications initialed the MAR, or the staff who gave the medication to the client.

Although these allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

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