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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430701864
Report Date: 05/24/2022
Date Signed: 05/24/2022 04:07:48 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
05/17/2022 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20220517140703
FACILITY NAME:LYTTON GARDENS COMMUNITY CAREFACILITY NUMBER:
430701864
ADMINISTRATOR:DORIS LEEFACILITY TYPE:
740
ADDRESS:649 UNIVERSITY AVENUETELEPHONE:
(650) 617-7338
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:55CENSUS: 40DATE:
05/24/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Doris LeeTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility is not posting notices about a positive COVID case
Facility is providing residents' personal information to outside parties without consent.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced initial complaint investigation visit and met with Anahi McKane, Assisted Living Manager.

During visit, LPA Marrufo interviewed staff S1 and S2. LPA Marrufo obtained copies of the following documents: May Activities Calendar, Quarantine Sign posted on resident R1's door, and Facility Letter sent to Assisted Living families dated May 13, 2022. LPA Marrufo toured the facility, including facility entrance/exit, Assisted Living auditorium, elevators, and the Independent Living floors on the 3rd and 4th floor.

During interview, S1 stated that when there was a resident COVID-19 positive case in the Assisted Living portion of the facility, Administrator Lee notified the Assisted Living residents and their families by letter. See LIC9099-C for more information. Page 1 of 2.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
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-20220517140703
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: LYTTON GARDENS COMMUNITY CARE
FACILITY NUMBER: 430701864
VISIT DATE: 05/24/2022
NARRATIVE
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Administrator Lee stated that she did not notify the Independent Living residents of the COVID case because they do not mingle with the Assisted Living residents. She stated the Assisted Living and Independent Living residents do not share activity or dinning rooms. She stated the only portions of the facility that the Independent Living and Assisted Living residents share are the elevators and the facility entrance/exit. She stated there were no notices of the COVID case posted on the facility elevators or entrance/exit.

During facility tour, LPA Marrufo observed that there were no postings on the facility elevators or entrance/exit.

During interviews with S1 and staff S2, both stated that there was an incident in which facility staff S3 provided a listing of resident names, apartment numbers, and telephone numbers to a group of volunteers who had arranged an event at the facility. The group of volunteers then took the listing and knocked on residents' doors notifying them of the group's event.

Based on records review, interviews, and observations, the Department determines that there is preponderance of evidence to prove the alleged violations did occur. Therefore the allegations are substantiated.

See 9099-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Anahi McKane and a copy of the report and appeal rights were provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 26-AS-20220517140703
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: LYTTON GARDENS COMMUNITY CARE
FACILITY NUMBER: 430701864
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/31/2022
Section Cited
CCR
87468.1(a)(10)
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87468.1 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: (10) To be informed of the licensee’s policy concerning visits and other communications with residents,
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Licensee agrees to update the facility plan to notify Independent Living residents of COVID cases in the Assisted Living portion of the facility and submit the plan to CCL by POC date.
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according to Health and Safety Code section 1569.313. This requirement was not met as evidenced by: Licensee did not ensure that notices were posted in the elevators and entrances shared with Assisted Living to notify Independent Living residents that there was a positive COVID case in the facility, which posed a potential safety risk to residents in care.
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Type B
05/31/2022
Section Cited
CCR
87506(c)(1)
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87506(c)(1) Resident Records: (c) All information and records obtained from or regarding residents shall be confidential.(1) The licensee shall be responsible for storing active and inactive records and for safeguarding the confidentiality of their contents. The licensee and all
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Licensee agrees to conduct a staff training regarding safeguarding the confidentiality of residents' personal information by POC date and submit a roster of staff trained and their signatures, training topics, and name and qualitifications of trainer to CCL by POC date.
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employees shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative. This requirement was not met as evidenced by: Licensee did not ensure that the confidentiality of resident information was safeguarded, which poses a potential 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.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3