415600255-12-27-2021-14-AS-JMOS-CB9PHS-20220202102021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600255
Report Date: 12/27/2021
Date Signed: 12/27/2021 10:12:19 AM

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
10/18/2021 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20211018083952

FACILITY NAME:	SUNRISE OF SAN MATEO		FACILITY NUMBER:	415600255
ADMINISTRATOR:	STEPHANIE HALL		FACILITY TYPE:	740
ADDRESS:	955 S EL CAMINO REAL		TELEPHONE:	(650) 558-8555
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY:	85	CENSUS:	DATE:	12/27/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Josephine Chan		TIME COMPLETED:	10:25 AM

ALLEGATION(S):

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Resident sustained injuries while in care

INVESTIGATION FINDINGS:

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On December 27, 2021, Licensing Program Analyst (LPA) Komal Charitra met with Dining Service Coordinator, Josephine Chan to deliver the findings for the above allegation.

Regarding the allegation that resident sustained injuries while in care. On October 17, 2021, Resident (R1) sustained a fall. According to the complainant, R1 was found on the floor covered with blood with bruises and skin tears. According to Administrator, R1 is independent and can perform his daily activities without staff supervision.

Based on the interviews conducted during the investigation, R1 was admitted about 5 years ago as “independent living.” Because R1 was admitted as independent living, he/she did not require staff to check on R1 as often as assisted living residents. R1 was able to voice concerns on his own. (CONTINUE TO 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

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-20211018083952

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: SUNRISE OF SAN MATEO	FACILITY NUMBER: 415600255
	VISIT DATE: 12/27/2021

NARRATIVE

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Although, R1 sustained new injuries from this incident, facility records document that the resident was independent and did not require multiple checks, resident was alert and able to verbalize needs.

Therefore, based on the information collected, and interviews, the allegation that the resident sustained injuries while in care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred

Report is reviewed with Josephine Chan and a copy is provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2021

LIC9099 (FAS) - (06/04)

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