415600191-1-30-2021-14-AS-KHOS-BYYLNV-20210310075455

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600191
Report Date: 01/30/2021
Date Signed: 01/30/2021 02:18:36 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
09/15/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200915165543

FACILITY NAME:	ATRIA DALY CITY		FACILITY NUMBER:	415600191
ADMINISTRATOR:	CECILIA DAUTH		FACILITY TYPE:	740
ADDRESS:	501 KING DR		TELEPHONE:	(650) 878-5111
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	120	CENSUS: 59	DATE:	01/30/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Karina Luna		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff failed to observe and adapt needs and services plan as needed

INVESTIGATION FINDINGS:

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On 1/30/2021 Licensing Program Analyst (LPA) Jaime Vado is conducted an unannounced 10 day tele-inspection to deliver findings regarding the allegations received. This investigation was conducted by the Department's Investigations Branch in conjunction with LPA. LPA spoke resident services director Karina Luna.

During the course of the investigation medical records are reviewed, resident records, and interviews conducted with DPOA and individuals involved with the care of R1. It was found that the facility re-assessed R1 multiple times and R1 received medical attention for falls where injuries were sustained. Facility staff provided supervision for R1 with regularly scheduled room checks. In addition R1 had one on one supervision from an outside agency for overnight hours for additional care and supervision. Although the facility provided the supervision for R1, assessed R1's needs and services multiple times, and having a private caregiver R1 continued to fall and sustain injuries despite care measures and supervision put in place by facility and responsible party of R1.

Based on these observations, the above allegation 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. Report is discussed with administrator about the process and how the facility will receive a copy of this report and the e-signing of this document. A copy of this report is sent to resident care director.

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: 01/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2021

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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