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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600444
Report Date: 07/14/2021
Date Signed: 07/14/2021 11:10:13 AM

Substantiated


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
06/21/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210621131629
FACILITY NAME:CHAD CORNER ASSISTED LIVINGFACILITY NUMBER:
415600444
ADMINISTRATOR:SANTOTOMAS, CARMELITA P.FACILITY TYPE:
740
ADDRESS:2901 SHANNON DR.TELEPHONE:
(650) 588-5391
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
07/14/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:AdministratorTIME COMPLETED:
11:20 AM
ALLEGATION(S):
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Resident is being illegally evicted.
INVESTIGATION FINDINGS:
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On 07/14/2021, Licensing Program Analyst Murial Han conducted an unannounced visit on behalf of LPA Christopher Hopkins to deliver the finding. LPA Han met with the Administrator, Carmelita Santotomas and explained the purpose of the visit.

The allegation of illegal eviction relates to an incident when a resident was admitted by the facility from the hospital on 6/17/2021. Shortly after the admission (two days later), the licensee determined that was not able to provide the level of care that R1 required.

Instead of following eviction procedures, on 6/19/2021 the resident was transferred to the hospital and licensee refused to readmit the resident.

This report is continued onto LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
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 3
Control Number 14-AS-20210621131629
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: CHAD CORNER ASSISTED LIVING
FACILITY NUMBER: 415600444
VISIT DATE: 07/14/2021
NARRATIVE
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Based on this information, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated.

Deficiency is cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached LIC 9099D.

This report is discussed, reviewed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20210621131629
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: CHAD CORNER ASSISTED LIVING
FACILITY NUMBER: 415600444
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/21/2021
Section Cited
CCR
87224(c)
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EVICTION PROCEDURES
(c) The licensee shall, in addition to either serving the required thirty (30) days notice , sixty (60) days notice or seeking approval from the Department and service three (3) days notice on the resident, notify or mail a copy of the notice to quit to the resident's responsible person.
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The Administrator will immediate review the regulation and no later than 7/21/2021 to submit evidence that this has been completed.
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This requirement was not met as evidence by the facility refused to readmit R1 after R1 was hospitalized and the facility did not issue a 30-day eviction notice nor a 3-day notice which poses an immediate health, safety or personal rights risk to client.
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3