415601105-3-17-2023-14-AS-KHOS-CQCNEX-20230328102441

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601105
Report Date: 03/17/2023
Date Signed: 03/17/2023 10:48:49 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
02/16/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230216132540

FACILITY NAME:	FAMILY AFFAIR CARE HOME		FACILITY NUMBER:	415601105
ADMINISTRATOR:	LESLIE, HUI C.		FACILITY TYPE:	740
ADDRESS:	3100 COLLEGE DR.		TELEPHONE:	(650) 871-5095
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	10	CENSUS: 5	DATE:	03/17/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Leslie Hui		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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-Illegal eviction

INVESTIGATION FINDINGS:

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On March 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Leslie Hui and explained the purpose of the visit.

Regarding the allegation of illegal eviction, according to the reporting party, On February 15, 2023, Resident #1 (R1) was sent to the hospital by the facility staff for reason of “pneumonia.” The reporting party indicated the hospital wanted to release R1 back to the facility the same day, however facility stopped answering the hospital’s phone calls and locked the facility doors. Furthermore, R1 had to spend the night at the hospital.

During the investigation, LPA reviewed R1’s file, conducted interviews, reviewed R1’s discharge notes from 2/15/23-2/16/23. According to the administrator, the facility did not want to take the resident back because the administrator received two phone calls (name and position was unknown according to administrator) indicating that R1 had pneumonia, however later in the day the administrator received another call, (name and position was unknown as well according to administrator) indicated R1 did not have pneumonia. According to the administrator, she was unsure what to believe and wanted to contact R1’s responsible party to get his/her opinion prior to taking R1 back. In addition, the administrator stated that when R1 came back to the facility, both her and another staff were helping another resident for about 30 minutes and by the time someone got to the door, there was no one there. (CONT. TO 9099C)

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: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

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-20230216132540

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: FAMILY AFFAIR CARE HOME	FACILITY NUMBER: 415601105
	VISIT DATE: 03/17/2023

NARRATIVE

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Based on the interviews conducted, R1 indicated that the Co-Administrator told him/her to fake his/her symptoms. When taken to the hospital, R1 confirmed he/she did not have pneumonia. In addition, according to the on-call nurse on 2/15/23, the hospital called the facility notifying them of R1’s discharge, however the Administrator was refusing to take R1 back. The On-Call nurse then called the facility to notify them that R1 does not have pneumonia. According to the hospital staff interviewed, the Case Manager and the Emergency Department Nurse call the Administrator as well to confirm that R1 did not have pneumonia, is stable and is going to get discharged from the hospital. Furthermore, when R1 was taken back to the facility, the facility lights were off, the doors were locked, and no one was opening the door. Based on the discharge documents reviewed, R1 did not have any signs of pneumonia both clinically, on x-rays, and on exams. In addition, discharge documents indicated, when R1 was returned to the facility, the facility shut off it's lights and locked the doors after noticing that EMS returned with the R1.

The preponderance of evidence standard has been met; therefore, the above allegation is determined to be Substantiated as the facility administrator acknowledged that she refused to allow R1 to return back to the facility until R1's responsible party assessed R1 prior to returning. In addition, it was indicated that the administrator did not assess the R1 when at the hospital and did not reassess R1 when he/she returned back to the facility.

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, Leslie Hui and a copy is provided with appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230216132540

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: FAMILY AFFAIR CARE HOME	FACILITY NUMBER: 415601105
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/24/2023 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463 Reappraisals: (a) ...The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to... Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Facility administrator to review CCR 87463 and submit acknowledgement to LPA. In addition, administrator to submit a written plan to address concerns regarding what facility can do if hospital does not properly assess resident prior to discharge.
	8 9 10 11 12 13 14	Based on interviews conducted and information collection, the facility administrator acknowledged that she refused to take R1 back to the community because the hospital did not properly assess her, however instead of administrator going to assess her, the administrator called R1's responsible party to assess R1 prior to discharge. In addition, the administrator acknowledged she did not reassess R1 when R1 was in the hospital or when R1 returned back to the community.	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: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC9099 (FAS) - (06/04)

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