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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600019
Report Date: 03/25/2026
Date Signed: 03/25/2026 12:52:51 PM

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
03/20/2026 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260320092212
FACILITY NAME:PROVIDENCE PLACEFACILITY NUMBER:
385600019
ADMINISTRATOR:KNOP, GALINAFACILITY TYPE:
740
ADDRESS:2456 GEARY BLVD.TELEPHONE:
(415) 359-9700
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:34CENSUS: 33DATE:
03/25/2026
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Catherine AquinoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility staff worked without a criminal record clearance
INVESTIGATION FINDINGS:
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On 3/25/2026, LPA Grace Donato made an unannounced complaint investigation visit to the facility. LPA met with Health & Wellness Director (HWD) Catherine Aquino. LPA explained the purpose of the visit.

For the allegation of facility staff worked without a criminal record clearance, Reporting Party (RP) reported that RP did not obtain a criminal record clearance prior to working with residents.

During the investigation the HWD admitted to having a staff worked at the facility with no fingerprint clearance.

An immediate civil penalty of $500 was assessed due to a staff member not having a fingerprint clearance.

Deficiencies are cited under the California Code of Regulations. Failure to correct the deficiencies by the POC due date may result in Civil Penalties.

A copy of this report along with Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
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 3
Control Number 14-AS-20260320092212
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: PROVIDENCE PLACE
FACILITY NUMBER: 385600019
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/25/2026
Section Cited
CCR
87355(j)
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(j) The licensee shall maintain documentation of criminal record clearances or criminal record exemptions of employees in the individual's personnel file as required in Section 87412, Personnel Records.

This requirement is not met as evidenced by:
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Licensee has already terminated staff and has submitted the POC.
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Based on records review, the licensee did not comply with the section cited above due to S1 having no criminal record clearance while working in the facility which poses an immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
03/20/2026 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260320092212

FACILITY NAME:PROVIDENCE PLACEFACILITY NUMBER:
385600019
ADMINISTRATOR:KNOP, GALINAFACILITY TYPE:
740
ADDRESS:2456 GEARY BLVD.TELEPHONE:
(415) 359-9700
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:34CENSUS: 33DATE:
03/25/2026
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Catherine AquinoTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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2
3
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9
Facility staff worked without the required training
INVESTIGATION FINDINGS:
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On 3/25/2026, LPA Grace Donato made an unannounced complaint investigation visit to the facility. LPA met with Health & Wellness Director (HWD) Catherine Aquino. LPA explained the purpose of the visit.

Regarding staff training, RP stated that the facility failed to provide the 40 hours of mandated dementia and caregiver training required before an employee is permitted to work independently.

Based on interviews, HWD mentioned that they provided training for staff. Three other staff member were interviewed and all mentioned that S1 was trained by them. S2 mentioned that S1 was trained with medication.

For the records review, LPA observed training certificates signed by HWD. There are also in-service training log signed by two trainers. LPA reviewed other staff records and all showed that staff recieved required training from the facility.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Report is reviewed and copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2026
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 3