435202623-6-22-2023-26-AS-KHOS-CTDJC4-20230703065516

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 06/22/2023
Date Signed: 06/22/2023 04:15:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 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
03/25/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200325172553

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	SAULNIER, AMY		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 70	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Fatima Vicente-Dimanlig		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident sustained a fracture while in care
Resident is not receiving appropriate catheter care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Fatima Vicente-Dimanlig, Resident Care Director. On 03/25/2020, the Department received the complaint with the above allegations. On 03/27/2020, LPA Marrufo conducted the initial complaint investigation visit.

An Incident Report filed by the facility on 03/24/2020 states that resident R1 was seen by the nurse on duty after R1’s fall on 03/22/2020. The Incident Report states R1 reported having 3/10 pain on R1’s right ankle. An assessment was done and there was noted to be discoloration on R1’s right ankle area. 911 was called for further assessment. Paramedics were unable to determine if R1’s right foot was fractured. R1 initially refused to go to the emergency room, but eventually requested to be taken. R1’s Progress Notes from 03/22/2020 state that at 7:08 AM, staff were trying to assist R1 from R1’s bed to R1’s wheelchair. R1 reported that R1’s knees were feeling weak and went down to the floor slowly with assistance from the staff. See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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-20200325172553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 06/22/2023

NARRATIVE

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An assessment was done and no apparent injury was noted. R1 denied any pain or discomfort. Staff notified R1’s spouse and R1’s Primary Care Physician (PCP) visited R1 at 10:00 AM. PCP noted R1 was able to move all extremities at baseline and R1 continues to deny pain or discomfort.

The Transfer/Discharge Report dated 04/23/2020 states that R1’s diagnoses include fracture of lower end of right fibula and muscle weakening and atrophy on multiple sites.

R1’s Appraisal/Needs and Services Plan states that R1 needs two staff to assist R1 with transferring. This assessment was completed on 05/05/2018.

During interview, R1 stated that two staff assisted R1 during transfer on 03/22/2020. R1 stated to not remember who the two staff were. R1 stated to have confidence in the abilities of facility staff.

During interview, staff S1 stated to not be able to recall who were the two staff who assisted R1’s transfer on 03/22/2020. S1 is the staff who wrote the Incident Report.

R1’s Physician’s Report states R1 is not able to care for R1’s own toileting needs.

R1’s Appraisal/Needs and Services Plan states R1 needs to be provided with frequent assistance to change R1’s incontinent product.

R1’s Progress Notes from 02/13/2020 notes R1 continues to wear condom catheter and a new bag was put in place. In-service done with care team for proper instructions.

The facility Training Participation Log states on 03/18/2020, a training on Condom Catheter and Urostomy was provided to staff.

See LIC9099-C for more information. Page 2 of 3.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 26-AS-20200325172553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 06/22/2023

NARRATIVE

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R1’s Intervention Logs for January, February and March 2020 include “Remove catheter at daytime” and “Bladder Continence” as interventions. Each intervention has an entry specifying the intervention was completed for each required instance.

During interview, R1 stated to not recall how staff emptied out R1’s catheter. R1 stated to not recall if there were any times the staff emptied the catheter on the carpet or if R1’s apartment had an odor of urine. R1 stated R1 would “probably remember something like that because it is gross.” R1 stated to remember urinating into a container and the container never leaked.

LPA did not observe an odor of urine in R1’s living unit during visit.

Staff S1 stated to have never observed any times R1’s living unit smelled like urine. S1 stated to have never had any concerns of staff emptying R1’s catheter on the carpet or floor.

Based on information from interviews conducted with staff and resident, and records reviewed, although the allegations listed above may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

This report was reviewed with Fatima Vicente-Dimanlig and a copy of the report was provided.

Page 3 of 3. END REPORT.

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

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
CENTRAL COAST CR/RES, 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
03/25/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200325172553

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	SAULNIER, AMY		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 70	DATE:	06/22/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Fatima Vicente-Dimanlig		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Resident illegally evicted.

INVESTIGATION FINDINGS:

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Staff S2 stated that there is no Eviction Notice in R1’s resident record.

On 03/26/2020, R1’s Family Member (FM1) stated during interview that the facility had contacted R1’s spouse and let the spouse know that the facility would be able to receive R1 back to the facility after R1 is discharged from a rehabilitation facility. FM1 stated that R1 would be placed in a skilled nursing facility. FM1 stated the facility left a care package with R1’s spouse stating they are looking forward to receiving R1 back at the facility after R1’s rehabilitation.

LPA Marrufo observed R1 at the facility during visit. During interview, R1 stated to have never received an Eviction Notice from the facility. R1 stated to not recall being told verbally by a facility staff that R1 was being evicted. See LIC9099-C for more information. Page 1 of 2.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 26-AS-20200325172553

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 06/22/2023

NARRATIVE

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R1’s updated Appraisal/Needs and Services Plan states R1’s move in date is 04/29/2020.

This agency has investigated the complaint allegations listed. Based on interviews, review of records, and observations, the CCLD has found that the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report was reviewed with Fatima Vicente-Dimanlig and a copy of the report was provided.

Page 2 of 2.

END REPORT

SUPERVISOR'S NAME: Sarah Yip	TELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 06/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5