415600219-2-5-2026-14-AS-ACON-DRG34B-20260219165453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600219
Report Date: 02/05/2026
Date Signed: 02/05/2026 01:38:17 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
11/21/2025 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20251121084815

FACILITY NAME:	SONAS HOME		FACILITY NUMBER:	415600219
ADMINISTRATOR:	RYAN, EVELYN B.		FACILITY TYPE:	740
ADDRESS:	886 GULL AVENUE		TELEPHONE:	(650) 577-9909
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	6	CENSUS: 4	DATE:	02/05/2026
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Evelyn Ryan		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff abandoned resident at the hospital.
Staff did not provide a 30 day notice to responsible party.

INVESTIGATION FINDINGS:

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On February 5, 2026, Licensing Program Analyst (LPA) Murial Han conducted a visit to deliver the complaint investigation findings. LPA met with administrator, Evelyn Ryan and caregiver, Daisy Tubbs and LPA explained the purpose of today's visit.

Regarding allegation of – staff abandoned resident at the hospital, the reporting party stated that the administrator/licensee refused to re-admit resident #1 (R1) after R1’s hospitalization resulted in R1 discharged to a skilled nursing facility.

As part of the investigation, LPA interviewed the administrator/ licensee, staff, Golden Gate Regional Representative (GGRC), Hospital Discharge Planner, R1’s responsible party and reviewed hospital records.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

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-20251121084815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SONAS HOME	FACILITY NUMBER: 415600219
	VISIT DATE: 02/05/2026

NARRATIVE

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According to the administrator/licensee, prior to R1’s hospitalization, R1 already required a higher level of care that the facility can't provide. She stated that R1 was high risk for fall, R1 had many sessions of physical therapy and many doctor’s appointments. She stated that since R1’s hospitalization, she has visited R1 and R1 presented with medical conditions that required a higher level of care such as high risk for fall, difficulty with swallowing, and a foley catheter. In addition, the administrator/ licensee stated she has visited R1 at the skilled nursing facility where she observed R1 of having a one – to – one caregiver and needed a lot more assistance than Sonas Home can provide.

According to R1’s responsible party, initially the administrator/ licensee stated that R1 cannot return to the facility unless R1 had a night sitter because she felt R1 was at risk for fall and R1 needed a higher level of care so the responsible party spoke with Golden Gate Regional Center and a night sitter was granted. Then, administrator/licensee stated that the sitter needed to be trained so they can care for R1. The responsible party stated that the administrator/licensee was making excuses not to take R1 back despite R1 being back to his/her baseline upon discharge from the hospital. In addition, the responsible party stated that R1’s discharge documentation from the doctor indicated that R1 can return to the board and care home with increased caregiver support.

According to the GGRC Representative, GGRC was in support of R1 returning to the facility as it was recommended by R1’s hospital discharge planner and hospital physician. GGRC has arranged for additional staffing support upon R1’s return. In addition. The licensee was informed that they would work with the facility either to provide additional staffing support to care for R1 or assist with discharge planning in a proper process.

According to the hospital discharge planner, R1 required some assistance with Activities of Daily Living (ADLs) but R1 did not get up unattended at night. The discharge planner stated that the discharge plan was for R1 to return to the board and care, but the administrator did not want to take R1 back due to lack of staff at night. Subsequently, additional night staff was provided but the administrator continued not willing to take R1 back. Therefore, R1 was discharged to a skilled nursing facility despite R1 being back to baseline upon discharge.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 14-AS-20251121084815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SONAS HOME	FACILITY NUMBER: 415600219
	VISIT DATE: 02/05/2026

NARRATIVE

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According to former staff #1 (S1) and current staff #2 (S2), R1 was able to walk with a walker with some supervision and R1 required some assistance with toileting and showering. They stated that R1 was not difficult to care for and R1 was very calm and pleasant.

Based on the hospital discharge note, it indicated that once the board and care and or family arranged for increased caregiver support then R1 will return there.

Based on hospital physical therapy treatment note dated 11/19/2025, R1 was making great progress, and the recommendation was returned to board and care facility with assistance from home health physical therapy.

Based on GGRC annual and quarterly reviews, it indicated that the licensee and staff verbalized that R1 was easy to care for, and R1 was a sweet person. In addition, it indicated that additional help was offered to the licensee for caring for R1 but it was declined by the licensee. The documentation did not indicate that R1’s care was increasing and required additional support.

After the investigation, this allegation is deemed to be substantiated as the hospital records, the physical therapy and the physician indicated that R1 has made great progress, and they recommended R1 to return to board and care with additional staffing. GGRC was in support of R1 returning home and arranged for additional support, but the licensee continued not willing to take R1 back resulted in R1 transferring to a skilled nursing facility. Furthermore, the Facility Program/Plan of Operation, it stated that Sonas Home’s goal is to provide 24 hours / 7 days assistance and care with ADLs ( bathing, dressing, grooming, feeding) , however, they refused to take R1 back who required the level of care that was described in the Facility Program as per the physical therapist note dated on 11/21/25 (the day prior to R1’s discharge) that R1 was ambulating in to chair/bathroom in hallway with minimum assist with a Front Wheel Walker (FWW), safety maintained.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 14-AS-20251121084815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SONAS HOME	FACILITY NUMBER: 415600219
	VISIT DATE: 02/05/2026

NARRATIVE

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Regarding to allegation of – staff did not provide a 30-day notice to responsible party, the reporting party stated that the licensee denied R1’s admittance back to the facility when R1 was ready to be discharged from the hospital and the 30-day eviction notice was not provided.

As part of the investigation, LPA interviewed R1’s responsible party, and the licensee.
The licensee denied the allegation and stated that two written notices via email dated November 21, 2025 and November 30, 2025, were sent to varies recipients and one of them was R1’s responsible party. The licensee stated that the emails served as a 30-day notice that indicated the facility will not be able to readmit R1 as R1 required a higher level of care.

LPA interviewed R1’s responsible party who acknowledged of receiving the above emails. However, the responsible party had no idea that the licensee would not allow R1 back to the facility even after additional staffing support was arranged by Golden Gate Regional Center (GGRC).

Based on the documents provided, LPA observed the 30-days notice emails were provided to the responsible party and others, but it did not include all the required details based on the regulation. Therefore, the 30-day notices via email were invalid as they were not incompliance.

After the investigation, this allegation is deemed to be substantiated.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator/ Licensee and caregiver.

A copy of the report and Appeal Rights were provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 14-AS-20251121084815

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SONAS HOME	FACILITY NUMBER: 415600219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/05/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/06/2026 Section Cited CCR 87224(a)	1 2 3 4 5 6 7	87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5)...This requirement is not met as evidenced by based on interviews and record	1 2 3 4 5 6 7	The administrator will review the regulation and provide a signed and dated statement indicating of the review. After the review, the administrator will develop a plan of correction to prevent this from
	8 9 10 11 12 13 14	reviews, R1 was hospitalized due to a change in health condition and the administrator/licensee refused to take R1 back to the facility despite additional staffing support was arranged by GGRC, hospital physician and other disciplines agreed that R1 has made good progress and shall return to the facility which posed an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14	happening again. The administrator will provide a copy of the statement and a copy of the plan of correction to CCL by 2/6/2026.
Type A 02/06/2026 Section Cited CCR 87224(d)(1)(B)1.2	1 2 3 4 5 6 7	87224 Eviction Procedures (d) The licensee shall set forth in the notice to quit the reasons..(1) The notice to quit shall include the following information: (B) Resources available to assist in identifying alternative housing.. but are not limited to, the following:1.Referral services..2. Case management organizations	1 2 3 4 5 6 7	The administrator will review the regulation and provide a signed and dated statement indicating of the review. After the review, the administrator will develop a plan of correction to prevent this from
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on interviews, observations and record reviews, the administrator/licensee provided two 30-day eviction notices to R1's responsible party and both notices did not contain the required information which posed an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14	happening again. The administrator will provide a copy of the statement and a copy of the plan of correction to CCL by 2/6/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026

LIC9099 (FAS) - (06/04)

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