410508853-4-9-2021-14-AS-JMOS-C2YTLJ-20210513144938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410508853
Report Date: 02/22/2021
Date Signed: 04/09/2021 04:04:39 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
07/02/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200702090107

FACILITY NAME:	CLM CARE HOME		FACILITY NUMBER:	410508853
ADMINISTRATOR:	MARINELA M. LIM		FACILITY TYPE:	740
ADDRESS:	1320 VALOTA ROAD		TELEPHONE:	(650) 298-9835
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	6	CENSUS: 5	DATE:	02/22/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marinela Lim		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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9

Licensee yells at residents

INVESTIGATION FINDINGS:

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On February 19, 2021 at 1030 LPA Jaime Vado conducted an unannounced complaint
tele-inspection to deliver findings in the allegations recieved. LPA spoke to licensee/administrator Marinela Lim and explained the purpose of today's tele-inspection.

During the investigation LPA conducted multiple interviews. It was confirmed that the licensee/administrator yelled at staff in the presence of residents. It was also confirmed in interviews that some residents were yelled at on occasion. Licensee admitted to yelling in front of residents during interview conducted by LPA.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

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 being sent to licensee email address and hardcopy to be mailed to facility.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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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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
07/02/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200702090107

FACILITY NAME:	CLM CARE HOME		FACILITY NUMBER:	410508853
ADMINISTRATOR:	MARINELA M. LIM		FACILITY TYPE:	740
ADDRESS:	1320 VALOTA ROAD		TELEPHONE:	(650) 298-9835
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	6	CENSUS: 5	DATE:	02/22/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marinela Lim		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Licensee is attempting to illegally evict resident

INVESTIGATION FINDINGS:

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2
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5
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12
13

On February 19, 2021 at 1030 LPA Jaime Vado conducted an unannounced complaint
tele-inspection to deliver findings in the allegations recieved. LPA spoke to licensee/administrator Marinela Lim and explained the purpose of today's tele-inspection.

During the investigation LPA conducted mulitple interviews. According to interviews the administrator was not trying to evict the resident. It was described to LPA that there was a disagreement about resident conduct. In the disagreement with the administrator and resident it was said an eviction notice "could be" issued if the conduct continued. The facility was not trying to evict the resident at that time as it was meant to prevent an eviction. The information was incorrectly understood by the resident and there was no eviction notice issued to the resident.

Based on these observations, the above allegation is UNSUBSTANTIATED.
Although the 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 above allegations are unsubstantiated at this time.

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 being sent to licensee email address and hardcopy to be mailed to facility.

Unsubstantiated

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: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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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Control Number 14-AS-20200702090107

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: CLM CARE HOME	FACILITY NUMBER: 410508853
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/22/2021 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87468.1(a)(1) licensee shall self certify the review of resident personal rights personal rights training to be taken. Evidence of training to be received.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Licensee admitted to yelling at staff in front of residents. LPA also confirmed with two other parties that residents were yelled at on occasion	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC9099 (FAS) - (06/04)

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