415600080-8-2-2021-14-AS-KHOS-C69JV8-20210826072242

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600080
Report Date: 07/19/2021
Date Signed: 08/02/2021 04:01:02 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
07/15/2021 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210715102701

FACILITY NAME:	SAN MATEO VILLA		FACILITY NUMBER:	415600080
ADMINISTRATOR:	VIDUCICH, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	1661 MCKINLEY STREET		TELEPHONE:	(650) 570-6475
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY:	6	CENSUS: 3	DATE:	07/19/2021
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Elizabeth Viducich		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Illegal Eviction

INVESTIGATION FINDINGS:

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***THIS IS AN AMENDED REPORT MARKING THE REPORT AS PUBLIC***

On 07/19/2021 at 1330 LPA Jaime Vado conducted an unannounced complaint inspection visit to deliver findings on the allegation received.

During the course of the investigation LPA conducted interviews and made observations. It was found that there was a misunderstanding between the licensee and hospital regarding the discharge of the resident back to the facility. The facility was not going to allow the resdient back due violations of the admission agreement after the resident was admitted to the ER for health concerns. Responsible family member of the resident informed that she would be transferred to another facility but there was no action regarding this by the responsible family member. The facility allowed the resident back in the facility on 07/15/2021 around 1800hrs.

Based on these observations, the above allegations are 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.

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: 07/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2021

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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