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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430700136
Report Date: 03/22/2022
Date Signed: 03/22/2022 03:03:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/25/2021 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20210825085147
FACILITY NAME:CHANNING HOUSEFACILITY NUMBER:
430700136
ADMINISTRATOR:GONZALEZ-MENDOZ, YADIRA S.FACILITY TYPE:
741
ADDRESS:850 WEBSTER STREETTELEPHONE:
(650) 327-0950
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:264CENSUS: 217DATE:
03/22/2022
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Yadira Gonzalez-MenozaTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Resident sustained fracture(s) while in care.
INVESTIGATION FINDINGS:
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On 08/25/2021, the Department received a complaint with the above allegation. On 08/26/2021, the Department conducted an initial complaint investigation visit.

During the morning shift on 07/17/2021, facility staff discovered resident R1’s injury. The morning care staff reported nothing unusual occurred during their shift. The previous shifts on 07/16/2021 also reported nothing unusual occurred during their shifts. There are no endorsements or pass downs about arm injuries related to R1 that week.

R1’s Assisted Daily Living (ADL) chart shows staff conducted activity checks. The staff helped with rotations, incontinence care, and baths, but nothing was noted out of the ordinary.
See LIC9099-C for more information. Page 1 of 2.
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: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
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
Control Number 26-AS-20210825085147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136
VISIT DATE: 03/22/2022
NARRATIVE
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During interview, witness stated R1 was fine on 07/16/2021 and did not notice any injuries when R1 was given a full bath.

During interview, facility staff suspected the injury was caused unintentionally during transfer or repositioning only because they could not identify any obvious explanations, like a fall or intentional harm by staff.

Based on hospital medical records, R1 was admitted to the hospital from 07/17/2021-07/20/2021 for a “closed displaced oblique fracture, of shaft of right humerus fracture.”

Based on records review, interviews with staff and witnesses, and observations there is preponderance of evidence to prove the alleged violation did occur, therefore the allegation is substantiated.

See LIC9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Administrator Yadira Gonzalez-Mendoza and a copy of the report and appeal rights were provided.

Page 2 of 2.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20210825085147
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: CHANNING HOUSE
FACILITY NUMBER: 430700136
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
03/23/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 (a)(2) Personal Rights of Residents in All Facilities

(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable
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Licensee agrees to submit a plan to conduct staff training on safely repositioning and transferring residents. Staff training rosters shall be submitted to CCL with roster of staff trained, date of training(s), and name and qualifications of trainer.
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accommodations, furnishings and equipment. This requirement was not met as evidenced by: Licensee did not ensure safe transferring or repositioning of resident R1. Resident R1 sustained a right arm fracture while in care. This possess an immediate safety risk to residents in care.
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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: 03/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3