415600616-6-21-2021-14-AS-KHOS-C48KUY-20210622081332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600616
Report Date: 06/15/2021
Date Signed: 06/21/2021 09:18:36 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
06/01/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210601132624

FACILITY NAME:	NEW CEDAR LANE CARE HOME, INC.		FACILITY NUMBER:	415600616
ADMINISTRATOR:	DIAZ, YOLANDA		FACILITY TYPE:	740
ADDRESS:	924 CEDAR STREET		TELEPHONE:	(650) 728-3132
CITY:	MONTARA	STATE: CA	ZIP CODE:	94037
CAPACITY:	17	CENSUS: 9	DATE:	06/15/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Rosa Diaz		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Resident is required to clean litter box.

INVESTIGATION FINDINGS:

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On 6/ 15 / 21 Licensing Program Analyst (LPA) Murial Han conducted an unannounced inspection to deliver the findings of this complaint. LPA met with the Administrator, Rosa Diaz and delivered the finding.

Regarding allegation that resident is required to clean litter box, the facility recently admitted a resident who has a cat. The complainant had indicated that the resident is required to clean the litter box. During the investigation, LPA interview Resident 2 (R2) and inspected the facility rooms. R2 has a cat and denied that she is required to clean the litter box. R2 stated that facility staff clean the litter box daily, and she may help to clean it here and there, but she is certainly not required to do it.

This report is continued onto LIC 9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

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-20210601132624

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: NEW CEDAR LANE CARE HOME, INC.	FACILITY NUMBER: 415600616
	VISIT DATE: 06/15/2021

NARRATIVE

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The staff members and the Administrator also acknowledged that facility staff cleans the box and room and denied that R2 is required to clean the room and the box.

LPA reviewed R2's monthly invoice which includes cat care by the facility.

Based on records review, we have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

This report was discussed and reviewed with the Administrator and a copy was provided.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2021

LIC9099 (FAS) - (06/04)

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