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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 01:23:55 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
11/30/2020 and conducted by Evaluator Shabana Buksh
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201130134243
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:
01:00 PM
MET WITH:Maria HartTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Licensee speaks inappropriately to resident
Licensee is not assisting resident with hygiene needs
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 11/30/2020, the Department received the complaint with the above allegations. An initial unannounced virtual facility inspection was conducted on 12/02/2020.

Regarding the allegation that Licensee speaks inappropriately to resident. The reporting party (RP) stated that 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. Per the RP, at one point during the Zoom meeting the licensee began yelling at the resident saying "You're lazy. She doesn't listen to me because she is lazy". The RP stated that later in the meeting the RP asked the licensee 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!"


Continues on next page LIC 9099C
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 4
Control Number 14-AS-20201130134243
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
05/01/2021
Section Cited
CCR
87468.1(a)(1)
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PERSONAL RIGHTS OF ALL RESIDENTS
Residents in all residential care facilities for the elderly shall have the personal right...
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met, as evidenced by information obtained from interviews with clients and/or their responsible
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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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parties. Licensee failed to be respectful, courteous, patient and responsive to the needs of R1 which poses an immediate health, safety or personal rights risk to clients in care. Licensee was heard on Zoom Meeting, yelling at the resident saying "You're lazy.
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Type A
05/01/2021
Section Cited
CCR
8768.2(a)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
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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 and record reviews, Licensee failed to deliver care, supervision and services that met the needs of R1. This posed an immediate Health, Safety and Personal Rights risk to residents in care. Based on interviews and photograph, R1 was seen unkempt.

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

DATE: 04/30/2021
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
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
11/30/2020 and conducted by Evaluator Shabana Buksh
COMPLAINT CONTROL NUMBER: 14-AS-20201130134243

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:
01:00 PM
MET WITH:Maria HartTIME COMPLETED:
01:23 PM
ALLEGATION(S):
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Licensee does not maintain a comfortable temperature in the facility
INVESTIGATION FINDINGS:
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On April 30, 2020, Licensed Program Analyst (LPA) Buksh, conducted a unannounced complaint investigation and spoke with Licensee's Daughter, Maria Hart..

Regarding the allegation that Licensee does not maintain a comfortable temperature in the facility. LPA took a vitual tour of the facility with Staff, (S1). LPA asked S1 to place a thermometer in the hallway and the reading was 70 degrees F on 12/02/2020. LPA observed one of the resident (R2) was in t-Shirt and shorts. R1 was siting in the wheelchair with a thin blanket over her. Licensee stated she doesn't like showing her arms. Based on observation, it was determined that every resident at the home had different levels of temperature tolerance. LPA discussed individual care plan and how a comfortable temperature for each resident would be maintained at the home. At the time of the investigation, the room temperature was maintained at the home within the temperature range. Regulation 87303 b(1) states "The facility shall heat rooms that residents occupy to a minimum of 68 degree F, (20 degrees C)". 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: 4 of 4
Control Number 14-AS-20201130134243
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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Continues...

Regarding the allegation that Licensee is not assisting resident with hygiene needs. Based on the observation, photograph, interviews and statements, it was determined that Licensee and her husband who is the only staff seen at the facility were not able to provide the hygiene need of R1. The Licensee, with the assistance of her husband, were having difficulty lifting the resident from her wheelchair. R1 required a high level of care which the facility was not able to provide. Facility refused to hire private aid and also did not hire additional staff.

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.
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 4