410500567-2-10-2021-14-AS-JMOS-BYAW2X-20210216155504

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410500567
Report Date: 09/28/2020
Date Signed: 02/10/2021 08:57:53 AM

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
05/11/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200511161139

FACILITY NAME:	SEQUOIAS-PORTOLA VALLEY, THE		FACILITY NUMBER:	410500567
ADMINISTRATOR:	APRIL THOMPSON		FACILITY TYPE:	741
ADDRESS:	501 PORTOLA ROAD		TELEPHONE:	(650) 851-1501
CITY:	PORTOLA VALLEY	STATE: CA	ZIP CODE:	94028
CAPACITY:	328	CENSUS: 251	DATE:	09/28/2020
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	April Thompson		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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9

Facility is in disrepair
Facility staff failed to maintain a comfortable temperature for resident(s)

INVESTIGATION FINDINGS:

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On September 28, 2020 at 1530hrs Licensing Prgram Analyst (LPA) Jaime Vado conducted an unannounced complaint tele-inspection regarding the allegations recieved. LPA spoke to the admnistrator April Thompson.

During the course of this investigation, LPA conducted interviews with the administrator, R1, and the family of R1. It is discovered, that the resident lives in the independent portion of the facility. This is confirmed by the administrator and family members of R1. Supplemental documentation is recieved confirming this. The family of R1 does confirm that the allegations are not true and the facility addressed what they could to meet the needs of R1. CDSS does not provide oversight into the independent living portion of the facility

Based on the information obtained, the above allegation is UNFOUNDED, meaning that the allegation is false, could not have happened and/or is without a reasonable basis. Report is discussed with administrator about the process in which the facility will receive a copy of this report and the e-signing of this document. A copy of this report is sent to adminsitrator April Thompson at 1700hrs on September 28, 2020.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2020

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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