435202629-9-13-2021-26-AS-RMAO-C79SEH-20210927134847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202629
Report Date: 09/13/2021
Date Signed: 09/13/2021 10:50:34 AM

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
02/12/2021 and conducted by Evaluator Joanne Roadilla

COMPLAINT CONTROL NUMBER: 26-AS-20210212081029

FACILITY NAME:	BLENDED FAMILY CARE HOME		FACILITY NUMBER:	435202629
ADMINISTRATOR:	PAGKALINAWAN, MICHELLE		FACILITY TYPE:	740
ADDRESS:	10366 MILLER AVENUE		TELEPHONE:	(408) 802-6410
CITY:	CUPERTINO	STATE: CA	ZIP CODE:	95014
CAPACITY:	12	CENSUS: 9	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Michelle Pagkalinawan		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident sustained injuries while in care resulting in hospitalization due to facility staff not changing catheter in a timely manner.
Resident is not receiving physical therapy as needed.

INVESTIGATION FINDINGS:

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LPA Joanne Roadilla conducted an unannounced complaint investigation visit to deliver findings of the above allegations. LPA met with Administrator (ADM) Michelle Pagkalinawan and discussed the purpose of the visit.

On 02/12/2021, LPA Gladys Kuizon conducted an initial investigation. During the visit, facility’s current resident roster, facility staffing schedule from November 2020 - January 2021, all residents' Restricted Health Care plans and corresponding physician's orders and needs and services plan for all residents with Restricted Health Conditions, and log sheet of all home health visits from November 2020 - January 2021 were obtained.

Continued on LIC9099-C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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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Control Number 26-AS-20210212081029

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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
	VISIT DATE: 09/13/2021

NARRATIVE

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Based on interviews with home health nurse (RN) and facility staff (S1-S4), all of their statements regarding the care of resident’s (R1) catheter were consistent that facility staff were only trained and instructed to drain R1's urine bag and to monitor for any signs or symptoms of urinary tract infection (UTI). At no time were staff ever taught or instructed to change R1's catheter or urine bag.

Based on facility documents, medical and home health records review, on or around 06/30/2020, R1's catheter came out. R1 was referred to a medical professional (MD) who attempted to re-insert a new catheter but was unsuccessful. The MD did not feel R1 needed to have a catheter and R1 would be fine without one. Instead, R1 wore an undergarment and staff were instructed to change R1 frequently at two-hour intervals.

Based on staff (S1) interview, S1 stated that staff changed R1's undergarment every 45-60 minutes because R1 urinated frequently. S1 stated that on or around 01/25/2021, staff observed that R1’s private part was swollen. Staff immediately reported to home health RN and contacted R1’s primary care physician (PCP) about R1's medical condition. R1 was recommended to be transported to the emergency department (ED) but R1 refused due to problems with medical insurance. The following day, R1 developed a fever and R1’s private part became more swollen. Community care licensing (CCL) was informed of R1’s condition and staff continued to monitor R1’s condition. Paramedics were called to assess but R1 continued to refuse medical treatment.

On 01/30/2021, R1 agreed to be transported to the ED after R1's responsible party (RP) confirmed that R1's health insurance would pay for the ED visit. R1 was admitted into the hospital and was discharged on 02/09/2021. R1 was treated with a two-week course of antibiotic and a new Foley catheter was replaced.

Continued on LIC9099-C.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 26-AS-20210212081029

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: BLENDED FAMILY CARE HOME	FACILITY NUMBER: 435202629
	VISIT DATE: 09/13/2021

NARRATIVE

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Based on hospital and home health records, physical therapy services were never ordered. Home health only provided R1 with wound care services and monthly catheter cleaning and changing.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited during today's visit. Report was discussed with and a copy provided to Michelle Pagkalinawan.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Joanne Roadilla	TELEPHONE: (408) 205-2348
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

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