410500567-2-16-2021-14-AS-KHOS-BYJPG6-20210224101748

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410500567
Report Date: 02/16/2021
Date Signed: 02/16/2021 04:08:05 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
11/06/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20201106115205

FACILITY NAME:	SEQUOIAS-PORTOLA VALLEY, THE		FACILITY NUMBER:	410500567
ADMINISTRATOR:	CHERYL CARTNEY		FACILITY TYPE:	741
ADDRESS:	501 PORTOLA ROAD		TELEPHONE:	(650) 851-1501
CITY:	PORTOLA VALLEY	STATE: CA	ZIP CODE:	94028
CAPACITY:	328	CENSUS: 37	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Cheryl Cartney		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained injuries while in care
Resident developed an infection while in care
Resident's room is unkempt
Staff spoke to resident in an inappropriate manner
Staff closed resident's bank account without authorization
Staff financially abused resident

INVESTIGATION FINDINGS:

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On September 28, 2020 at 1515hrs Licensing Prgram Analyst (LPA) Jaime Vado conducted an unannounced complaint tele-inspection regarding to deliver findings regarding the allegations recieved. LPA spoke to the facility administrator Cheryl Cartney and explained the purpose of today's tele-inspection.

During the course of this investigation, LPA conducted interviews with the administrator, R1, and the family of R1. The resident lives in the independent living portion of the facility. This is confirmed per the administrator and family members of R1. Supplemental documentation is recieved confirming this. LPA also recieved information from county contacts that R1's allegations are false as well due to her being in independent living and R1's mental status. 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 Cheryl Cartney on February 16, 2021.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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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