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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410500567
Report Date: 10/06/2023
Date Signed: 10/06/2023 01:44:48 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/16/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230316122510
FACILITY NAME:SEQUOIAS-PORTOLA VALLEY, THEFACILITY NUMBER:
410500567
ADMINISTRATOR:APRIL THOMPSONFACILITY TYPE:
741
ADDRESS:501 PORTOLA ROADTELEPHONE:
(650) 851-1501
CITY:PORTOLA VALLEYSTATE: CAZIP CODE:
94028
CAPACITY:328CENSUS: 300DATE:
10/06/2023
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Pam MarronTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is not accepting resident back after discharge from a skilled nursing unit
INVESTIGATION FINDINGS:
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On this day Licensing Program Analysts (LPA) Jaime Vado and John Calandra conducted an unannounced complaint investigation visit to deliver the findings regarding the allegation received. LPA met with Resident Services Director Pam Marron and explained the purpose of today's visit.

During the course of the investigation interviews were conducted with the faciilty, the resident, the complainant, and other outside agencies. Interdepartmental agencies also assisted in the investigation in order to reach a finding. The resident was seeking placement back into an independent living unit. Per facility assessments and policy he is not able to return to independent living due to ambulatory status. The resident has been in the facility's SNF for several months. The facility has not complied with the transfer process required by health and safety code as outlined. The facility has not followed the transfer process as indicated in health and safety code. Per the records reviewed and recommendations provided the resident should be discharged from the facility SNF and transferred to assisted living to meet his/her needs. The allegation is substantiated.

Based on LPA interviews, items, and letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with Pam Marron
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
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 2
Control Number 14-AS-20230316122510
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIAS-PORTOLA VALLEY, THE
FACILITY NUMBER: 410500567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/26/2023
Section Cited
HSC
1788(a)(10)(A)-(C)
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Provisions of Contract - (a) A continuing care contract shall contain all of the following: (10) The procedures and conditions under which a resident may be voluntarily and
involuntarily transferred from a designated living unit. The transfer procedures, at a
minimum, shall include provisions addressing all of the following circumstances under
which a transfer may be authorized:
(A) A continuing care retirement community may transfer a resident under the
following conditions, taking into account the appropriateness and necessity of the
transfer and the goal of promoting resident independence:
(i) The resident is nonambulatory. The definition of "nonambulatory," as provided
in Section 13131, shall either be stated in full in the continuing care contract or be
cited. If Section 13131 is cited, a copy of the statute shall be made available to the
resident, either as an attachment to the continuing care contract or by specifying that it
will be provided upon request. If a nonambulatory resident occupies a room that has a
fire clearance for nonambulatory residents, transfer shall not be necessary.
(ii) The resident develops a physical or mental condition that is detrimental to or
endangers the health, safety, or well-being of the resident or another person.
(iii) The resident's condition or needs require the resident's transfer to an assisted
living care unit or skilled nursing facility, because the level of care required by the
resident exceeds that which may be appropriately provided in the living unit.
(iv) The resident's condition or needs require the resident's transfer to a nursing
facility, hospital, or other facility, and the provider has no facilities available to
provide that level of care.
(B) Before the continuing care retirement community transfers a resident under any
of the conditions set forth in subparagraph (A), the community shall satisfy all of the
following requirements:
(i) Involve the resident and the resident's responsible person, as defined in
paragraph (6) of subdivision (r) of Section 87101 of Title 22 of the California Code of
Regulations, and upon the resident's or responsible person's request, family members,
or the resident's physician or other appropriate health professional, in the assessment
process that forms the basis for the level of care transfer decision by the provider. The
provider shall offer an explanation of the assessment process, which shall include, but
not be limited to, an evaluation of the physical and cognitive capacities of the resident.
An assessment tool or tools, including scoring and evaluating criteria, shall be used in
the determination of the appropriateness of the transfer. The provider shall make
copies of the completed assessment to share with the resident or the resident's
responsible person.
(ii) Prior to sending a formal notification of transfer, the provider shall conduct a
care conference with the resident and the resident's responsible person, and, upon the
resident's or responsible person's request, family members, and the resident's health
care professionals, to explain the reasons for transfer.
(iii) Notify the resident and the resident's responsible person of the reasons for the
transfer in writing.
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(iv) Notwithstanding any other provision of this subparagraph, if the resident does
not have impairment of cognitive abilities, the resident may request that his or her
responsible person not be involved in the transfer process.
(v) The notice of transfer shall be made at least 30 days before the transfer is
expected to occur, except when the health or safety of the resident or other residents is
in danger, or the transfer is required by the resident's urgent medical needs. Under
those circumstances, the written notice shall be made as soon as practicable before the
transfer.
(vi) The written notice shall contain the reasons for the transfer, the effective date,
the designated level of care or location to which the resident will be transferred, a
statement of the resident's right to a review of the transfer decision at a care
conference, as provided for in subparagraph (C), and for disputed transfer decisions,
the right to review by the Continuing Care Contracts Branch of the State Department
of Social Services, as provided for in subparagraph (D). The notice shall also contain
the name, address, and telephone number of the department's Continuing Care
Contracts Branch.
(vii) The continuing care retirement community shall provide sufficient preparation
and orientation to the resident to ensure a safe and orderly transfer and to minimize
trauma.
(viii) For disputed transfer decisions, the provider shall provide documentation of
the resident’s medical reports, other documents showing the resident’s current mental
and physical function, the prognosis, and the expected duration of relevant conditions,
if applicable. The documentation shall include an explanation of how the criteria set
out in subparagraph (A) are met. The provider shall make copies of the completed
report to share with the resident’s responsible person.
(C) The resident has the right to review the transfer decision at a subsequent care
conference that shall include the resident, the resident's responsible person, and, upon
the resident's or responsible person's request, family members, the resident's physician
or other appropriate health care professional, and members of the provider's
interdisciplinary team. The local ombudsperson may also be included in the care
conference, upon the request of the resident, the resident's responsible person, or the
provider.
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Facility shall ensure to follow the items outlined under CCRC Provisions of Contract regarding resident transfers. Review and proof of understanding is to be recieved by the Department.
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This health and safety code requirement has not been met as evidenced by: Facility did not follow the rules as outlined in HSC 1788(a)(10)(A)-(C) regarding resident trasfers.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023
LIC9099 (FAS) - (06/04)
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