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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600223
Report Date: 02/03/2023
Date Signed: 02/03/2023 11:21:10 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
01/31/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230131162849
FACILITY NAME:STERLING COURTFACILITY NUMBER:
415600223
ADMINISTRATOR:CHARLES, SARAH ST.FACILITY TYPE:
740
ADDRESS:850 NO. EL CAMINO REALTELEPHONE:
(650) 344-8200
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:24CENSUS: 17DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Executive Director, Sarah St. CharlesTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff not providing resident records to resident's authorized person
INVESTIGATION FINDINGS:
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On February 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Executive Director, Sarah St. Charles and Director of Assisisted Living, Novie-Ann Villafuerte and explained the purpose of the visit.

According to the reporting party, the facility staff are not providing copies of resident records to the responsible party. During the visit, LPA reviewed Resident 1's (R1's) file and interviewed the Executive Director. According to the Executive Director, the facility did not send R1's responsible party R1's records as requested because the facility wanted to seek legal counsel to ensure they can send all of R1's confidential records to the responsible party. In addition, according to the Executive Director, the records have still not been provided to the authorized person.

Based on the information and interviews conducted, it was determined that Staff are not providing resident records to resident's authorized person. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Director of Assisisted Living, Novie-Ann Villafuerte and a copy is provided with appeals rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 14-AS-20230131162849
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: STERLING COURT
FACILITY NUMBER: 415600223
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87506(c)(1)
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87506 Resident Records: (c) All information and records obtained from or regarding residents shall be confidential.(1) The licensee shall be responsible for storing active and inactive records... The licensee... shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.

Violation of this regulation is not met as evidence by:
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Executive Director will provide resident's responsible party with a copy of resident's file. In addition, Executive Director will submit a copy of email, fax cover sheet, or copy of receipt to CCLD as proof or correction.
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Based on information collected and interviews conducted, it was acknowledged by the Executive Director that the facility did not provide the authorized representitive resident documents because the facility wanted to seek legal counsel to ensure they can send all of R1's confidential records to the responsible party.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2