380500295-12-6-2024-14-AS-ACON-DBZV4V-20241216150654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380500295
Report Date: 12/06/2024
Date Signed: 12/06/2024 10:57:35 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/27/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 14-AS-20240327103010

FACILITY NAME:	HERITAGE ON THE MARINA		FACILITY NUMBER:	380500295
ADMINISTRATOR:	MARY LINDE		FACILITY TYPE:	741
ADDRESS:	3400 LAGUNA ST.		TELEPHONE:	(415) 202-0300
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94123
CAPACITY:	109	CENSUS: 81	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mary Linde, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Facility failed to report an incident to Licensing

INVESTIGATION FINDINGS:

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On 12/6/2024 Licensing Program Analyst (LPA), Tobola conducted an unannounced visit to deliver the complaint investigation findings. LPA met with Mary Linde and explained the purpose of the visit.

Regarding to the allegation of- facility failed to report an incident to licensing, the facility's LULA lift//elevator was malfunctioned in December, 2023 which resulted resident #1 (R1) being struck inside and the facility failed to report it to Community Care Licensing (CCL).

As part of the investigation, LPA interviewed the Director of Health Services who stated that he/she can not remember if the incident was reported to CCL and the facility was not able to provide proof that it was reported. Therefore, on March 20, 2024, the Director of Health Services completed an incident report for this incident that occurred in December 2023.

After the investigation, this allegation is substantiated as the facility was not able to provide proof that this incident was reported to CCL according to the Regulation- Reporting Requirement.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of the report and appeal rights were provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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 14-AS-20240327103010

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HERITAGE ON THE MARINA	FACILITY NUMBER: 380500295
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/06/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/17/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements..a) Each licensee shall furnish to the licensing agency such reports ..(1) A written report shall be submitted to the licensing..within seven days of the occurrence D) Any incident which threatens the welfare, safety or health of any resident,...	1 2 3 4 5 6 7	The administrator/licensee will develop a plan in writing to ensure the facility is in compliance with the regulation and the plan shall include staff education. The administrator will provide a copy of the signed and dated plan to CCL
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on interviews, and record review, facility's LULA lift was malfunctioned which resulted R1 being stuck and the facility did not reported it to CCL which poses a potential health risks to residents in care.	8 9 10 11 12 13 14	and a copy of the staff in-service record by the plan of correction due date of 12/17/2024.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/27/2024 and conducted by Evaluator Dominic Tobola

COMPLAINT CONTROL NUMBER: 14-AS-20240327103010

FACILITY NAME:	HERITAGE ON THE MARINA		FACILITY NUMBER:	380500295
ADMINISTRATOR:	MARY LINDE		FACILITY TYPE:	741
ADDRESS:	3400 LAGUNA ST.		TELEPHONE:	(415) 202-0300
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94123
CAPACITY:	109	CENSUS: 81	DATE:	12/06/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Mary Linde, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Elevator/ LULA lift is in disrepair
Facility has no designated person to cover for administrator while administrator is not present
Financial Malfeasance

INVESTIGATION FINDINGS:

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On 12/6/2024 Licensing Program Analyst (LPA), Tobola conducted an unannounced visit to deliver the complaint investigation findings. LPA met with Mary Linde and explained the purpose of today's visit.

Regarding to the allegation of- elevator/LULA lift is in disrepair, the reporting party stated that R1's was stuck in the LULA lift in between floors as it was malfunctioned.

As part of the investigation, LPA interviewed the maintenance director and reviewed documents that was provided by the facility.

According the the maintenance director, he/she was hired after the incident. However, he/she was endorsed of such incident that occurred in December 2023. The maintenance director stated that when the alarm was activated alerting that he LULA lift was broken, the elevator monitoring company responded immediately and the elevator was out of service for 2 week for repair.
Continued onto LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20240327103010

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HERITAGE ON THE MARINA	FACILITY NUMBER: 380500295
	VISIT DATE: 12/06/2024

NARRATIVE

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Based on documents provided by the facility, it revealed that the LULA lift was maintenance every month by the San Francisco Elevator Services.

During LPA's visit on 3/28/2024, LPA observed the LULA lift was in operating condition.

After the investigation, this allegation is unsubstantiated. The elevator was malfunctioned, however, the facility followed its preventive maintenance program as the elevator was being serviced on a monthly basis and the incident that happened in December 2023 was an accident and monitoring company responded immediately.

Regarding to the allegation of- facility has no designated person to cover for administrator while he/she is not present, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that when R1 was stuck in the LULA lift, there was no manager on the premises to assist the situation.

As part of the investigation, LPA interviewed the Director of Health Services who stated that there was always more than one manager at the facility during business hours and a manager was assigned to be on-call during non-business hours and the assigned manager would be answering calls from the facility and providing assistance 24/7.

Based on documents provided by the facility, LPA observed a list of on-call managers who rotates on a weekly basis.

After the investigation, this allegation is unsubstantiated as there was a designated manager covering the administrator when the administrator was not at the facility.

Regarding to the allegation of Financial Malfeasance, there is no additional information provided by the reporting party.

Based on the review of audited financial statements for fiscal year ends (FYE) 2021,2022, and 2023, Budget Presentations for FYE 2022 and interviews with the complainant and the Provider, the CCCB did not find instances of financial malfeasance related to the misuse of investment funds or monthly care fees.

After the investigation, this allegation is deemed to be unsubstantiated.

Although the above investigations 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 allegation is UNSUBSTANTIATED

A copy is provided.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC9099 (FAS) - (06/04)

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