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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700136
Report Date: 04/30/2021
Date Signed: 04/30/2021 02:54:54 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2020 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20200124104557
FACILITY NAME:CHANNING HOUSEFACILITY NUMBER:
430700136
ADMINISTRATOR:MATSUMOTO, MELVINFACILITY TYPE:
741
ADDRESS:850 WEBSTER STREETTELEPHONE:
(650) 327-0950
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:264CENSUS: 220DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rhonda BekkedahlTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Questionable Death
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted a complaint investigation visit over telephone and spoke with Rhonda Bekkedahl. The visit was conducted over telephone due to the ongoing COVID-19 Shelter-in-Place order throughout the county and state.

The Department received a complaint against the facility on 01/24/2020. On the same day, the Department conducted an initial complaint visit and obtained resident and staff records. On 01/22/2020, the Department received a Death Report from the facility stating that resident R1 had an unwitnessed fall in the facility on 01/16/2020 around 7:20 AM and later died at 10:49 PM at hospital due to intracranial hemorrhage. The Department conducted interviews with facility and hospital staff from 02/04/2020 through 03/24/2020.

See LIC9099-C for more information.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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 5
Control Number 26-AS-20200124104557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136
VISIT DATE: 04/30/2021
NARRATIVE
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Interviews with facility staff indicate that on 01/16/2020, staff S1 checked on R1 in R1’s room at 7:00 AM and then proceeded to check on the resident in the adjacent room. While checking on the next resident, S1 heard a thump sound in S1’s room. S1 returned to R1’s room and found R1 to be on the floor snoring. S1 called for assistance from S2. S2 conducted a check on R1, who did not complain of pain and exhibited good vital signs. The only observed injury was redness on the side of R1’s head, to which staff applied ice. S2 and S3 continued to conduct neuro checks on R1 every 15 to 30 minutes throughout the day and recorded normal results for R1.

At 8:50 AM, R1 vomited. At 9:30 AM, R1 vomited a second time and in response, S2 attempted to contact R1’s physician, who was not able to be contacted. S2 then requested advice from the on-call doctor, who requested a fax regarding R1’s condition. S2 then contacted R1’s daughter about R1’s fall and present condition, and R1’s daughter agreed to postpone sending R1 to the emergency room since R1’s vital signs were normal.

The on-call doctor stated during interview with the Department to have not been able to determine if R1’s death would have been avoided if facility staff brought R1 to the hospital immediately after the fall.

The Department review of R1’s care plan indicates that the facility followed the care plan to reduce the risk of R1 falling.

Based on interviews with facility and hospital staff and review of records, the Department finds the above allegation to be unsubstantiated, meaning that although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2020 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20200124104557

FACILITY NAME:CHANNING HOUSEFACILITY NUMBER:
430700136
ADMINISTRATOR:MATSUMOTO, MELVINFACILITY TYPE:
741
ADDRESS:850 WEBSTER STREETTELEPHONE:
(650) 327-0950
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:264CENSUS: 220DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Rhonda BekkedahlTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility staff failed to seek appropriate and timely medical attention for resident.
INVESTIGATION FINDINGS:
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On 01/16/2020, facility staff were aware of R1’s initial head injury when staff found R1 on the floor of R1’s apartment at approximately 7:20 AM. Facility staff observed redness to R1’s head and applied ice. At 8:50 AM, R1 had an episode of vomiting and at 9:30 AM R1 had a second episode of vomiting. At 9:30 AM, after learning that R1 vomited a second time, S3 contacted R1’s physician, who was not in the office. Therefore, the facility had to request advice from the on-call doctor. At 9:30 AM, R1’s daughter was informed of R1’s fall. At 10:30 AM, the on-call doctor sent over instructions approving of the facility in-house physician to evaluate R1. At 10:45 AM, R1 was non-responsive and 911 was called. R1 passed away at 10:49 PM at the hospital.

See LIC9099-C for more information.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 26-AS-20200124104557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136
VISIT DATE: 04/30/2021
NARRATIVE
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The Department reviewed medical records, which indicate that on 01/16/2020 R1 was taken to the hospital for a fall and was admitted. R1 was diagnosed with a hemorrhagic stroke.

Based on interviews with facility and hospital staff and review of records, the Department determines that the above allegation is substantiated, meaning that there is a preponderance of evidence to prove the allegation did occur.

An immediate civil penalty of $500.00 is being assessed against the facility today for a violation resulting in serious bodily injury to a resident in care. Additional Civil Penalties may be assessed for serious bodily injuries.

Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D. Report was discussed with Executive Director Rhonda Bekkedahl. A copy of this report and licensee’s Appeal Rights forms given to Executive Director. This report will be sent to Executive Director Rhonda Bekkedahl so that it can be signed and returned to CCL.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Citations on this Visit Report are Under Appeal!

Control Number 26-AS-20200124104557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
05/01/2021
Section Cited
CCR
87465(a)(1)
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87465(a)(1) Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by: Licensee did not seek timely medical care for R1 after R1 was found on the floor with a head injury and then was observed by staff to have
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Licensee agrees to submit a plan to CCL by POC date detailing how staff will be trained to arrange or assist in arranging appropriate medical and dental care in a timely manner based on
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vomited twice after the initial observation. 3 hours after staff initially found R1 on the floor, staff found R1 to have become non-responsive and then called 911 for R1, posing an immediate health risk to resident in care.
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the condition and needs of the residents. Once training is complete, licensee agrees to submit a roster of staff trained along with name of trainer and his/her qualifications and training date(s).
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5