410508747-7-14-2020-26-AS-GNWR-BS9SFD-20200807135006

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410508747
Report Date: 07/14/2020
Date Signed: 07/14/2020 04:25:49 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2020 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20200610145817

FACILITY NAME:	PENISONI CARE HOME		FACILITY NUMBER:	410508747
ADMINISTRATOR:	PENISONI, KOLOTINA L.		FACILITY TYPE:	740
ADDRESS:	2736 GEORGETOWN STREET		TELEPHONE:	(650) 323-5844
CITY:	EAST PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	9	CENSUS: 7	DATE:	07/14/2020
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Sione Penisoni		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff verbally threatened resident with eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit via telephone and met with Sione Penisoni. The visit was conducted via telephone due to the ongoing COVID-19 Shelter-in-Place order.

On 06/17/2020, LPA Marrufo conducted a tele-visit and spoke with facility staff S1 and resident R1. During interview, S1 stated to have not threatened R1 with eviction, but to have only warned R1 that R1 may be evicted. LPA Marrufo conducted a telephone interview with R1 who stated that R1 did not feel threatened or harassed by S1 when S1 warned R1 of eviction. R1 stated that there was no other staff or residents present during the time when S1 spoke with R1 about eviction. See LIC9099-C for more information. Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

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 2

Control Number 26-AS-20200610145817

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PENISONI CARE HOME	FACILITY NUMBER: 410508747
	VISIT DATE: 07/14/2020

NARRATIVE

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Based on information from interviews conducted with staff and resident, although the allegation listed above may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22. This report was reviewed with Sione Penisoni. A copy of the report was sent to him so that he may sign and return it to LPA Marrufo.

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SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2