415601175-12-16-2024-14-AS-ACON-DCGVPJ-20241231153649

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601175
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:54:33 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
05/29/2024 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240529154040

FACILITY NAME:	TLC HOME CARE V		FACILITY NUMBER:	415601175
ADMINISTRATOR:	MAURICIO, LILIA L		FACILITY TYPE:	740
ADDRESS:	716 NORTH HUMBOLDT ST		TELEPHONE:	(650) 952-1687
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	6	CENSUS: 5	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Joebelle Payumo and Rose Masagca		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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- Staff was unable to meet resident's overall care needs
- Resident left in soiled diapers/linens for extended periods of time.

INVESTIGATION FINDINGS:

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LPA Jeung interviewed staff.
Based on information reported by and obtained from facility staff and medical staff, these allegations are substantiated. The preponderance of evidence standard has been met.

Former client resided in facility from 1/4/24 to 5/5/24. Upon admission, she was diagnosed with vascular dementia and a hoyer lift was used for transfers; she was incontinent, as well. Starting on 1/8/24, client received home health visits from LVNs and/or RNs approximately 3x/week. On 1/29/24, staff reported that client refused to get out of bed, and that an open wound developed on coccyx. RN assessed the pressure injury as stage 2 on 1/31/24 and staff were instructed on how to care for wound. Despite regular wound care by nurses and staff, coccyx wound worsened. On 3/27/24, RN assessed the coccyx wound as stage 3, and noted a new wound on left hand.
Home health nurses noted that on 4 visits, client was soiled; visits were at 10 am, 1pm, 2pm and 3pm. On 4/22/24, insertion of a foley catheter may have been necessitated due to soiled wound dressings and soiled diapers. At the recommendation of client's medical provider, client was relocated to another RCFE.
Deficiencies of the California Code of Regulations, Title 22 are cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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

Control Number 14-AS-20240529154040

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: TLC HOME CARE V	FACILITY NUMBER: 415601175
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/16/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/27/2024 Section Cited CCR 87411(h)	1 2 3 4 5 6 7	PERSONNEL REQUIREMENTS All services requiring specialized skills shall be performed by personnel qualified by training or experience in accordance with recognized professional standards. This requirement was not met, as non-medical staff provided wound care on C1 pressure ulcer on days when visiting	1 2 3 4 5 6 7	Proof of correction to be sent to CCLD BY DUE DATE, describing how facility will meet the needs of clients who require skilled nursing care.
	8 9 10 11 12 13 14	LVNs and RNs did not visit client. Licensee failed to ensure that client received medical care from qualified personnel, which posed a potential health, safety or personal rights risk to clients in care.	8 9 10 11 12 13 14
Type B 12/27/2024 Section Cited CCR 87625(b)(3)	1 2 3 4 5 6 7	MANAGED INCONTINENCE In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for...ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.	1 2 3 4 5 6 7	Plan of correction to be sent to CCLD BY DUE DATE, which will describe how staff will ensure that incontinent residents are kept clean and dry.
	8 9 10 11 12 13 14	This requirement was not met, as client #1 was observed on at least 4 occasions within a 30-day period to be in a soiled diaper. Licensee failed to ensure that client who needed incontinent care as clean and dry, which posed a potential health, safety or personal rights 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.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
05/29/2024 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20240529154040

FACILITY NAME:	TLC HOME CARE V		FACILITY NUMBER:	415601175
ADMINISTRATOR:	MAURICIO, LILIA L		FACILITY TYPE:	740
ADDRESS:	716 NORTH HUMBOLDT ST		TELEPHONE:	(650) 952-1687
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	6	CENSUS: 5	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Joebelle Payumo and Rose Masagca		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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- Staff mismanaged resident's medication

INVESTIGATION FINDINGS:

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Based on incomplete information about medication that was purported to be missing, review of home health nursing notes and interview with staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

On 2/9/24, NP instructed staff to apply calmoseptine and aquaphor to coccyx wound of former resident after every incontinence care, and NOT to cover the wound with a dressing. In addition, on 3/25/24, client was prescribed Miconazole 2% cream to be applied twice daily.
Although it is alleged that staff were unable to locate one of these topical treatments, not enough information was provided to conduct an adequate investigation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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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