415600616-6-21-2021-14-AS-KHOS-C48KUZ-20210622081332

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600616
Report Date: 06/15/2021
Date Signed: 06/21/2021 09:17:17 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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Facility did not provide a safe and healthful living environment for resident.

INVESTIGATION FINDINGS:

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On 6/15/2021, 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 facility did not provide a safe and healthful living environment for resident, the complainant/reporting party is alleging that the living condition for Resident 1 (R1) significantly change when the facility admitted another Resident (R2) who had a cat. Complainant indicated that R1 has allergies that were exacerbated when the cat was introduced into the house.

LPA interviewed R1 who stated that he/she is not allergic to cats, as prior to coming to the assisted living he/she used to play, sleep and hold grandson’s cats all the time. R1 also stated to be aware that there is cat at the facility but has never seen it, as the cat is kept away from his room and common areas, and it does not bother R1 at all. Furthermore, R1 stated that he/she likes the facility, and it is a safe and healthy environment for them to live in.

This report is continued onto LIC9000-C

Unsubstantiated

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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During the investigation, complainant indicated that R1’s allergy medications were increased due to R1’s allergies. LPA reviewed the available documentation and noted that R1 has allergies; at one point R1 was prescribed prednisone, due to R1’s asthma, caused by dust, dandruff and allergens, for 5-days. The physician also recommended a HEPA filter, and cleaning instructions as well as cautioning against any pets in the common areas.

LPA observed R1's room has a HEPA filter, and R1’s room appears clean and in good repair. No dust was detected/observed on the bedside table and on the other furniture.

LPA interviewed staff who denied the allegation, stating that the cat stays in R2's room all the time and there are no animals at the common areas within the facility at any time. Staff also stated to be following R1's physician's instructions on daily and weekly cleaning and R1 validated that it is being done and necessary steps to ensure the facility is cleaned. In addition, they have not noticed any animal hair, and/or dandruff partials during their daily cleaning.

Based on record review, staff interviews and observation during the investigation, this allegation is unsubstantiated.

Although the allegation may have happened and/or valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the Administrator and a copy is 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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