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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435294340
Report Date: 08/12/2022
Date Signed: 08/12/2022 04:10:28 PM

Substantiated


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
01/15/2020 and conducted by Evaluator David Marrufo
COMPLAINT CONTROL NUMBER: 26-AS-20200115090530
FACILITY NAME:MOLDAW FAMILY RESIDENCES AT 899 CHARLESTONFACILITY NUMBER:
435294340
ADMINISTRATOR:ALEXANDER BEN ISRAELFACILITY TYPE:
741
ADDRESS:899 EAST CHARLESTON ROADTELEPHONE:
(650) 433-3600
CITY:PALO ALTOSTATE: CAZIP CODE:
94303
CAPACITY:270CENSUS: 188DATE:
08/12/2022
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Preet KaurTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility did not ensure changes in resident's condition were reported to a physician and responsible party.
Facility did not have an exception to retain a resident with a catheter.
Facility neglience resulted in resident sustaining serious bodily injury
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit to deliver the findings on the above allegations and met with Preet Kaur, Associate Executive Director.

On 01/17/2020, the Department conducted an initial complaint investigation visit regarding the above allegations and obtained copies of documents related to the complaint investigation. Between 1/22/20 and 5/28/2020, the Department conducted interviews and review of documents and made another facility visit on 07/22/2021.

9 facility staff, 1 family member, 2 agency staff and resident (R1) were interviewed. R1 was unable to communicate and did not respond to questions. 9 out of 9 facility staff stated there was no incident report done or concern of blood in urine brought to the attention of home health agency or primary doctor or family member. 2 out of 2 agency staff stated they were not informed of any concern of possible blood in urine.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
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 4
Control Number 26-AS-20200115090530
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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
VISIT DATE: 08/12/2022
NARRATIVE
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The review of End of Day reports dated 12/26/2019 through 1/3/2020 noted on 12/26/2019, 12/29/2019, 12/30/2019, 01/01/2020, 01/02/2020, and 01/03/2020, multiple staff noticed blood in R1’s urine. On 01/03/2020, facility staff S1 noticed a discharge coming from R1’s penis and reported the concern to the nurse on duty, S2. S2 stated during interview to have told S1 to “keep an eye on it.” S2 stated to have forgotten to have made a report on the incident to S2’s supervisor before leaving work. On 01/04/2020, R1 had a fever and on 01/05/2020, when R1 stood up, blood, pus, and urine “gushed onto the floor.” R1 was taken to the hospital by the family member on 1/5/2020 and was hospitalized. R1 was diagnosed with traumatic hypospadias with fibrinous exudate at the meatus. Facility staff were unable to provide any evidence that R1’s condition was reported to attending Home Health agency or primary care physician.

R1’s Physician’s Report and Appraisal/Needs and Services Plan indicate that R1 had been given a primary diagnosis of dementia. On 12/16/2019, the hospital discharged R1 to the facility with a catheter and discharge indicating arrangement with Home Health Agency for catheter care assistance once a week. In an email sent to the Department on 03/30/2022, staff S4 stated that the facility had no record of submitting an exception request for R1’s catheter.

The Department did not receive any exception request on the restricted health condition for R1’s use of a foley catheter. Facility did not have a plan of care to address the resident’s pulling of the catheter which resulted in injury, infection, and hospitalization.

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

An immediate civil penalty of $500.00 is being assessed against the facility today for violation resulting in serious injury to a resident in care. An additional Civil Penalty in the amount of $10,000.00 for violation Resulting in Serious Bodily Injury is pending review.

Deficiencies were cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 9099-D. Report was discussed with Assistant Executive Director Preet Kaur. A copy of this report and licensee’s Appeal Rights forms were provided. Appeals must be directed to Licensing Regional Manager.
SUPERVISOR'S NAME: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 26-AS-20200115090530
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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2022
Section Cited
CCR
87613(c)
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General Requirements for Restricted Health Conditions
(c) The licensee shall document any significant occurrences that result in changes in the resident’s physical, mental and/or functional capabilities and immediately report these changes to the
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Licensee agrees to submit a plan to CCL by POC date to retrain facility staff on identifying and reporting residents’ change in conditions for timely appropriate medical attention for residents. Licensee shall submit the plan to CCL by POC date and once training is completed, submit copies of training rosters with names of
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resident’s physician and authorized representative. This requirement was not met as evidenced by: facility staff failed to immediately report the changes to R1’s physical condition of possible blood in urine to R1’s physician/home health and authorized representative. Staff observed blood in urine as early as 12/29/19 but facility did not report until 1/5/2020 when authorized representative noticed the change during visit which resulted in serious bodily injury to R1.
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staff trained, names and certifications of trainers, and dates.
Type A
08/13/2022
Section Cited
CCR
87466
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Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual
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Licensee agrees to retrain facility staff on observing and reporting resident’s change in condition to resident representatives, including resident physician/home health and family members. Licensee shall submit the plan to CCL by POC date and once training is completed, submit copies
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weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement was not met as evidenced by: Facility staff failed to bring to the attention of R1’s physician and family representative when staff observed R1 had a penile discharge from 12/29/19 through 01/3/2020, which posed a serious health risk to residents in care.
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of training rosters with names of staff trained, names and certifications of trainers, and dates.
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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20200115090530
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: MOLDAW FAMILY RESIDENCES AT 899 CHARLESTON
FACILITY NUMBER: 435294340
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/12/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/13/2022
Section Cited
CCR
87616(a)
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87616(a) Exceptions for Health Conditions: As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of
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Licensee agrees to retrain facility staff on identifying prohibited and restricted health conditions and on submitting exception requests to the Department for residents with prohibited or restricted health conditions. Licensee shall submit the plan to CCL by POC date and once training is
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the law can be met through alternative means. This requirement was not met as evidenced by: the licensee did not submit an exception request for R1’s Foley catheter, which posed a serious health risk to residents in care.
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completed, submit copies of training rosters with names of staff trained, names and certifications of trainers, and dates.
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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: Sarah YipTELEPHONE: (408) 324-2131
LICENSING EVALUATOR NAME: David MarrufoTELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:

DATE: 08/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4