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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380500295
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:34:01 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/05/2021 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210805115835
FACILITY NAME:HERITAGE ON THE MARINAFACILITY NUMBER:
380500295
ADMINISTRATOR:MELVIN MATSUMOTOFACILITY TYPE:
741
ADDRESS:3400 LAGUNA ST.TELEPHONE:
(415) 202-0300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94123
CAPACITY:109CENSUS: 72DATE:
08/20/2021
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Hanh TaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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9
Residents are not assisted with their medication in a timely manner.
Complaint poster is not posted in the main entryway of the facility.
INVESTIGATION FINDINGS:
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On 08/20/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a 10-day follow-up complaint inspection visit with Operations Director (OD) Hanh Ta. LPA explained the purpose of the visit, reviewed the allegations, and delivered the findings.

Concerning the allegation of residents not assisted with their medication in a timely manner, LPA Filouane interviewed the OD and reviewed resident medication files. After review, this allegation is unsubstantiated.

Concerning the allegation of a complaint poster not posted in the main entryway of the facility, according to Title 22 regulations, there is not a specific location the complaint hotline poster is required to be posted. LPA Filouane toured the facility and verified the complaint hotline poster and ombudsman posters were placed throughout the facility, accessible to residents and staff. After review, this allegation is unsubstantiated.

Although the allegations 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.

This report was reviewed and discussed with the Operations Director and a copy will be emailed to the Operations Director.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
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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