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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410508691
Report Date: 04/30/2021
Date Signed: 04/30/2021 04:11:32 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
11/09/2020 and conducted by Evaluator Shabana Buksh
COMPLAINT CONTROL NUMBER: 14-AS-20201109111344
FACILITY NAME:OUR LADY OF PEACE RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508691
ADMINISTRATOR:SANCHEZ, LOLITA D. QUEFACILITY TYPE:
740
ADDRESS:1669 WOLFE DRIVETELEPHONE:
(650) 574-0498
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 0DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria Hart TIME COMPLETED:
02:55 PM
ALLEGATION(S):
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 Insufficient staff to meet the needs of the residents
Resident beyond the level of care of the facility
Reporting requirements
INVESTIGATION FINDINGS:
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On April 30, 2020, Licensed Program Analyst (LPA) Buksh, conducted an unannounced complaint investigation and spoke with Licensee's Daughter, Maria Hart. On 11/06/2020, the Department received the complaint with the above allegations. An initial unannounced virutal facility inspection was conducted on 11/16/2020.

Regarding the allegation the above allegations, Licensee and her husband are the only staff at the facility. Reporting party (RP) stated that he is concerned about the care the residents are receiving at this facility due to the licensee's cognitive issues. RP stated that he has observed licensee Lolita Sanchez's memory decline over time and RP believes licensee has dementia. LPA requsted a physician's report from the Licensee but no reports were provided to CCLD. RP stated the licensee makes promises to follow up with him, but then forgets. RP does not think the failure to follow up is intentional, but rather it is due to poor memory/cognitive functioning. RP stated he is particularly concerned about the well-being of one resident, (R1). RP stated resident (R1) has a brain injury and is non-communicative and requires a high level of care. LPA and other possible witnesses also had concerns reagrding Licensee's memory loss over the years. On 11/20/2020 they participated in a Zoom meeting with the resident R1, the licensee, the resident's Deputy Public Guardian/Temporary Conservator , the Licensee's granddaughter, and the RP.


Continues on next page
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
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 5
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
11/09/2020 and conducted by Evaluator Shabana Buksh
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201109111344

FACILITY NAME:OUR LADY OF PEACE RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508691
ADMINISTRATOR:SANCHEZ, LOLITA D. QUEFACILITY TYPE:
740
ADDRESS:1669 WOLFE DRIVETELEPHONE:
(650) 574-0498
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 0DATE:
04/30/2021
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Maria HartTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Staff sleeping in common areas
INVESTIGATION FINDINGS:
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On April 30, 2021, Licensed Program Analyst (LPA) Buksh, conducted an unannounced complaint investigation and spoke with Licensee's Daughter, Maria Hart.

Regarding the allegation that staff sleeps in the common area. LPA interviewed Licensee's Daughter. She stated that the staff never sleeps in the common area, they use the garage space for breaks. Per RP, when he knocked on the front door last week, it took licensee a long time to respond. RP said he had to knock extremely loud and it took a very long time for licensee to answer the door. During the initial inspection, LPA tested the door bell and it was operable. LPA made several visits to the facility before the pandemic and did not had to wait. The entrance/exit of the garage was clear during the virtual inspection.

Based on the interviews, and information collected during this investigation, it was determined THAT although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20201109111344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: OUR LADY OF PEACE RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508691
VISIT DATE: 04/30/2021
NARRATIVE
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Later in the meeting when Licensee was asked to demonstrate how she transfers the resident from a wheelchair to her bed. The RP, with the assistance of her husband, were having difficulty lifting the resident from her wheelchair, and the licensee began yelling at the resident "You're lazy!". Residents Responsible party stated that she offered Licensee private staff to take care of R1, but they refused. It was also learned that Licensee does not report any unusual incidents to the resident's responsible parties and to CCLD.

Based on interviews and information collected during the course of the investigation it was determined that the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. The deficiencies are cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Appeal Rights given.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20201109111344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OUR LADY OF PEACE RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508691
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2021
Section Cited
CCR
87411(a)
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87411(a)(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Licensee/Administrator agreed to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 or more per day.
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This requirement is not met, as evidenced by information obtained from interviews and statements. Licensee failed to provide sufficient staff to care for R1.
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Type B
05/12/2021
Section Cited
CCR
87463(a)
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87463 Reappraisal (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:
(3) Any illness, injury, trauma, or change in the health care needs of the resident that results in a circumstance or condition specified in Sections 87455(c) or 87615, Prohibited Health Conditions.
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Licensee/Administrator agreed to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 or more per day.
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This requirement is not met, as evidenced by; Based on interviews, statements and photographs, Licensee failed to document health changes in R1 which is potential Health and Safety risk to clients in care.

There was no appraisal or reappraisal documents on R1.
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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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20201109111344
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: OUR LADY OF PEACE RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508691
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/30/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/27/2021
Section Cited
CCR
87211(a)(1)
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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
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Licensee/Administrator agreed to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 or more per day.
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This requirement is not met evidenced by: Based on interviews and record reviews, licensee failed to incidents to Residents Responsible party and to Licensee which poses a potential Health, Safety or Personal Rights risk.

Licensee did not report unusual incidents to resident's responsible party and to CCLD.
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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.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 04/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5