San Carlos Elms

Type of visit: Case Management - Other

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on a substantiated complaint number: 14-AS-20190327094949, regarding an allegation that staff failed to provide care, supervision, and services to meet the needs of Resident 1(R1) resulting in R1 sustaining multiple injuries. LPA met with Administrator, Scott Evans and explained the purpose of the visit. On November 26, 2019, the Department concluded a complaint investigation and the allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.2(a)(4)” Additional Personal Rights of Residents in Privately Operated Facilities for facility failing to provide care, supervision and services that met R1's needs that resulted in R1 sustaining serious bodily injury. The investigation revealed that the plan of care for R1 was not individualized to tailor fit R1’s needs. Furthermore, R1’s hospitalization dated January 16, 2018, indicated R1 has a diagnosis of gait disorder and the physical therapist (PT) assessment notes dated March 1, 2018, identified R1 as high-risk for falls. The facility did not reassess the resident to develop a plan of care to meet R1’s needs. R1 had three separate incidents at the facility. On April 26, 2018, R1 was found on the floor and sustained a large skin tear to the left arm. On August 9, 2018, R1 stood up, fell on the floor, and sustained a fracture to the right hip. R1 was hospitalized and had surgery for a right hip fracture. Per document review and Administrator interview, there was insufficient staffing with only one staff on duty and that staff was assisting another client when R1 had the first two falls. The third incident was discovered when R1 was noted with back and leg pain on October 4, 2018. R1 continued to report pain during the night and continued to the next day. On October 5, 2018, around 2:00 p.m., R1 was reported to be in severe pain, and staff called R1’s family member and informed them the facility would call an ambulance to transfer R1 to the ER for evaluation. Two hours later at 4:00 p.m., the facility called an ambulance to transfer R1 to the ER. R1 was taken to the ER and R1 was diagnosed with a compression fracture in their back and a left hip fracture. (CONT. TO 809C) Based on interviews and record review, the facility was aware of R1’s risk for falls. However, the facility did not reassess R1 to update R1’s plan of care. The facility failed to reassess R1’s plan of care after the falls on April 26, 2018, and August 9, 2018. At the time of the complaint visit, on November 26, 2019, an immediate civil penalty of $500 was issued. The licensee was informed that an additional civil penalty was being determined and might be assessed based on Health and Safety Code § 1569.49. The Department has concluded an analysis and has determined that an additional civil penalty is warranted for a violation that resulted in R1 sustaining serious bodily injuries while under the care of this facility. Welfare and Institutions Code § 15610.67, defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by the licensee failing to provide proper care, supervision and services, which resulted in R1 sustaining multiple falls and injuries, that included a left hip fracture and a right hip fracture, which are serious bodily injuries. Today, October 18, 2023, the Department is issuing a civil penalty per Health and Safety Code 1569.49 for a violation that the Department constitutes as serious bodily injury in the amount of $10,000.00. However, since an immediate civil penalty of $500.00 was previously issued on November 26, 2019, the amount of the civil penalty issued today will be $9,500.00. A copy of the LIC 421D was given to Administrator, Scott Evans and originals were signed. Exit interview conducted with Administrator. A copy of the report issued. Appeal Rights provided. Administrator, Scott Evans signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.the state’s words, verbatim · CDSS document, Oct 18, 2023

Type of visit: Case Management - Deficiencies

On October 18, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to the case-management visit that was conducted on 9/22/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit. During the investigation conducted by the Department, it was revealed that Staff 1 (S1) had a clerical/administrative position while being employed at the facility. Based on documentation reviewed, S1 did not have any formal caregiving training to be able to provide care to residents at the facility. In addition, Staff 2 (S2) and Staff 3 (S3) acknowledged that S1 did not have any formal training in caregiving duties. During the investigation, it was also discovered that S1 required a criminal record exemption in October of 2020, however failed to complete the exemption process by January of 2021. S1 was disassociated from the facility on 1/12/2022 but continued to work in the facility until S1’s resignation on June 1, 2023. According to the staff interviewed, on May 27, 2023, the NOC shift had a last-minute call off and S1 offered to work overtime. S2 and S3 approved S1’s request for overtime as a last-minute caregiver to ensure the facility had enough staff for the night, however due to S1’s lack of training and caregiving experience, S1 was instructed to contact other caregivers on shift if a resident needed assistance. According to the Administrator, there are usually 3-4 NOC shift staff members, but on the evening of May 27, 2023 to the morning of May 28, 2023, there were only three staff members; S1, Staff 4 (S4) and Staff 5 (S5). During this shift, S4 only saw S1 when he/she arrived to work and denied having any further interaction with S1 the rest of his/her shift. S1 and S5 went to three resident rooms to provide incontinence care together, however at 3:18am, S1 was observed entering Resident 1’s (R1’s) room alone. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. This report is reviewed and discussed with Administrator; a copy of the report is provided with appeal rights. Copy of civil penalty is providedthe state’s words, verbatim · CDSS document, Oct 18, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 19, 2023

87411 Personnel Requirements - General: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… Violation of this regulation is not met as evidenced by: Based on documentation reviewed, and interviews conducted, it was acknowledged by the administrator that there are normally 3-4 caregivers that work NOC shift, however the night of 5/27/2023, there were only three staff members, one of which comprised of one administrative/clerical staff.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Licensee/Administrator will submit a plan in writing describing how facility will ensure sufficient staff throughout the day and ensuring staff are trained for assigned duties. Licensee/Administrator submitted an updated LIC500 to LPA

From the deficiency page — Deficiency type: Type A · Section cited: CCR87411(d) · Plan of correction due date: Oct 19, 2023

87411 Personnel Requirements - General: (d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: Violation of this regulation is evidenced by: Based on interviews conducted and documentation reviewed, S2 and S3 acknowledged that S1 did not have any formal caregiving training and lacked caregiving experience, however S1 was approved by S2 and S3 for overtime as a last-minute caregiver during the NOC shift on 5/27/2023.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Licensee/Administrator will submit a plan in writing to ensure current staff training includes; resident rights, assistance with ADLs, etc.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h) · Plan of correction due date: Oct 19, 2023

87405 Administrator - Qualifications and Duties: (h) The administrator shall have the responsibility to: (3) Develop an administrative plan and procedures to ensure clear definition of lines of responsibility, equitable workloads, and adequate supervision. Violation of this regulation is not met as evidenced by: Based on interviews conducted and documentation reviewed, S1 did not have any formal caregiving training to be able to provide care to residents at the facility, however approved to be a last-minute caregiver without adequate supervision. Nevertheless, S1 was able to sexually abuse R1 and R2 during his/her NOC shift on 5/27/2023.the state’s words, verbatim · CDSS document, Oct 18, 2023

Plan of correction: Administrator will submit a plan in writing to ensure that staff members assigned specific duties continue to provide their assigned job.

Type of visit: Case Management - Other

On September 22, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a case management visit that was conducted on 6/6/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit. On 6/6/2023, LPA conducted a case management visit to follow up on two incident reports. On 5/31/2023, Licensee reported that S1 allegedly sexually abused Resident 1 (R1) and Resident 2 (R2) on 5/28/2023. These incidents were referred to the Department’s Investigation Branch. During the investigation, the Department’s Investigator conducted record review, reviewed R1 and R2’s files, conducted interviews and reviewed the police report. Based on the interviews conducted, S1 worked NOC shift on 5/27/2023 and was instructed to stay at the front desk and monitor call lights from assisted living residents due to lack of training. In addition, staff interviewed indicated that S1 was instructed that if a call light activated, S1 would radio or call the memory care caregivers to assist the resident. According to Staff 2 (S2), the Memory Care Director who was on shift the day of the incident, it was acknowledged that S1 and S2 checked on R1 at around 1:35am, however R1 did not need any assistance. Camera footage observed shows S1 entering R1’s room alone at 3:18am. S2 denied being with S1 during this time. Furthermore, when administrator, Scott Evans asked S1 if he/she had entered R2’s room, initially S1 denied this allegation, however changed his/her answer and admitted he/she did enter R2’s room. (CONT. TO 809C) During the investigation, it was also noted that S1 was disassociated from the facility on 01/12/2021. S1 required a criminal record exemption effective 10/29/2020 as the Department received additional or subsequent criminal record information and that S1 no longer has a criminal record clearance. S1 had failed to complete the exemption process putting residents health and safety in the facility at risk. Deficiencies cited today under the California Code of Regulations, Title 22, Division 6, follows on LIC 9099D. An immediate civil penalty in the amount of $500 for a violation resulting in death and serious bodily injuries. The Licensee was informed that additional civil penalties may be assessed. Report a reviewed with Administrator and a copy is provided with appeal rights. Civil penalties are also provided.the state’s words, verbatim · CDSS document, Sep 22, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 23, 2023

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:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Violation of this regulation is not met as evidenced by: Based on the Department's interviews and record conducted, the Department found that S1 abused R1 and R2 which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 22, 2023

Plan of correction: Licensee/Administrator shall develop a plan of action in writing describing how the facility shall ensure personal rights of residents are observed by facility. Plan of correction to include plan to train staff. An immediate civil penalty in the amount of $500 for a violation resulting in death and serious bodily injuries. The Licensee was informed that additional civil penalties may be assessed.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(2) · Plan of correction due date: Sep 23, 2023

87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or... Violation of this regulation is not met evidenced by: Based on record review, S1 was not observed to be associated to the facility.the state’s words, verbatim · CDSS document, Sep 22, 2023

Plan of correction: Licensee/Administrator to submit a written plan describing how to ensure staff members maintain clearance, this includes routine audits. An immediate civil penalty of $1000.00 ($100/day x 10 days) will be issued today for S1.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87405(h)(1) · Plan of correction due date: Sep 23, 2023

87405 - Administrator - Qualifications and Duties: (h) The administrator shall have the responsibility to: (1) Administer the facility in accordance with these regulations and established policy, program and budget Violation of this regulation is not met as evidenced by: The administrator failed submit to the Department a completed exemption request on S1’s behalf to allow S1 to continue to work, reside or be present in the facility with criminal record clearance. The administrator also failed to immediately remove him/her from the facility as S1 was disassociated from the facility effective 01/12/2021 and continued to be employed at the facility until S1’s resignation (last date worked) 05/30/2023.the state’s words, verbatim · CDSS document, Sep 22, 2023

Plan of correction: Licensee shall develop a plan of action in writing describing how the facility shall ensure administrator performs duties and requirements according to regulations.

Type of visit: Office

On June 8, 2023 San Bruno Regional Office conducted a non-compliance conference meeting with Administrator, Scott Evans and Attorney, Joel Goldman. Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Cara Smith, and Licensing Program Analyst, Komal Charitra. During non-compliance meeting, the following violations were discussed, Additional Personal Rights of Residents in Privately Operated Facilities for Licensee failing to provide care, supervision and services that met Resident 1 (R1’s) needs that resulted in serious bodily injury sustained by R1. During this meeting, it was discussed, Community Care Licensing will increase frequency monitoring inspection visits to ensure compliance with this compliance plan of Title 22 regulation. Licensee was provided the link below for resources and guidance to improve facility operations: https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers The Administrator was informed that additional civil penalties may be assessed, pending review. Report is reviewed with the Administrator and a copy is provided via email. Administrator to sign report and submit to LPA by 6/8/23.the state’s words, verbatim · CDSS document, Jun 7, 2023

Type of visit: Case Management - Incident

On June 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on two incidents that were reported to CCLD on 6/5/2023. LPA met with Administrator, Scott Evans and explained the purpose of the visit. During the visit, LPA reviewed files and obtained copies of pertinent documents in relation to the incident. This incident requires further investigation. This report is discussed and reviewed with the Administrator, A copy is provided.the state’s words, verbatim · CDSS document, Jun 6, 2023

Type of visit: Required - 1 Year

On July 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID-19 signage posted on the front door. LPA met with Activities Director, Kathleen Sullivan and explained the purpose of the visit. Activities Director was able to provide LPA screening log documentation for visitors, residents and staff. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story building with rooms on each floor. LPA observed the laundry room on the first floor in good working condition. Due to the COVID-19 outbreak at the facility, the facility closed their dining room and is delivering meals to resident's rooms, however the tables was observed to be spread out. LPA observed the locked medication room and the 30-day PPE supply on the first floor. All communal bathrooms were observed to be equipped with liquid soap, paper towels, hand washing signage and a trash can with a lid. LPA observed the rooms with residents under COVID isolation to have COVID-19 postings regarding isolation, COVID precautions, and PPE donning and doffing. In addition, COVID-19 isolation rooms were equipped with a covered trash can outside the rooms. Infection control practices are reviewed: entry procedures, staff training and policies, resident/ visitors/ and staff daily monitoring records, and 30-day PPE supply LPA observed COVID-19 signage posted throughout the facility and in the facility elevator. Extra linen was observed to be present on each floor. Memory Care unit was observed to be on the 2nd and 3rd floor. CONT. to 809C Toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed. LPA requests the following documents to be submitted to CCLD by July 12, 2022: LIC309 Administrative Organization LIC308 Designation of Administrative Responsibility LIC500 Personnel Report LIC400 Resident Cash Resources LIC402 Surety Bond Administrator Certificate LIC610E Emergency Disaster Plan Report is reviewed with Kathleen Sullivan and a copy is provided. No citations issued during this visit.the state’s words, verbatim · CDSS document, Jul 5, 2022

Type of visit: Case Management - Other

On July 5, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on Death Report submitted to CCL Office on 6/28/22. LPA met with Activities Director, Kathleen Sullivan and explained the purpose of the visit. The Licensee reported on June 22, 2022, Resident 1(R1) was found in the bathroom floor faced down. According to the Licensee, R1 tried to ambulate with his/her walker but lost balance. R1 was found by a Med-Tech and was transported to the hospital shortly thereafter. During the visit, LPA observed R1's room, reviewed R1's file, and interviewed staff members. According to file reviewed and staff interviewed, R1 is an assisted living resident and has been a resident at the facility for 3 years. Interviewed staff indicated that R1 does not have a falling history and will call for help when he/she needed anything. According to interviewed staff, the day of the incident, R1 was alert and responsive during breakfast around 8:30am and at 10:20am, staff responded to R1's call. According to the Med-Tech who was present at the time of the incident, between 11:15am and 11:30am, R1 was found on the bathroom floor mumbling and semi-responsive. Med-tech immediately called 911. Facility records document that R1 is an assisted living resident and did require assistance with daily living activities, however R1 was able to express himself/herself. According to staff, assisted living residents get checked on every meal time unless resident's notify staff otherwise. No findings of foul play or fault were found by the facility. No citations were issued during the visit.the state’s words, verbatim · CDSS document, Jul 5, 2022