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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600658
Report Date: 11/06/2020
Date Signed: 11/06/2020 01:52:55 PM



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
10/26/2020 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201026102048
FACILITY NAME:DAMENIK'S HOMEFACILITY NUMBER:
415600658
ADMINISTRATOR:MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:851 BADEN AVENUETELEPHONE:
(650) 827-1100
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:15CENSUS: 14DATE:
11/06/2020
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Matt MontillaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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-Illegal eviction. Facility staff abandoned resident
INVESTIGATION FINDINGS:
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On 11/6/20 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator Matt Montilla via tele-visit due to Covid-19 procedures and explained the purpose of the tele-visit.

Regarding the allegation of illegal eviction, the Department investigation found the following: based on interview with Administrator, interview with Resident 1's (R1) responsible party, and information gathered, it was determined that R1 was sent to the hospital on 10/23/20, and once ready for discharge, the Licensee refused to take R1 back. R1 and/or R1's responsible party was never issued a 30 day eviction notice. If R1 was a danger to other residents and staff, the Licensee should have seeked written approval for a 3 day eviction from the CCLD.

Based on LPAs observations and interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

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

An exit interview was conducted. A copy of this report and appeal rights were discussed and emailed to Administrator Matt Montilla for signature.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
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-20201026102048
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: DAMENIK'S HOME
FACILITY NUMBER: 415600658
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2020
Section Cited
CCR
87224(c)
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87224 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.
This requirement is not met as evidenced by:
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Licensee has agreed to develop a written plan of correction (POC) describing how facility will ensure compliance with 87224(c). POC shall include measures to be implemented to prevent a repeated occurrence. Failure to correct this deficiency by due date may result in a civil penalty of $100 or more per day.
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Based on interviews and record review, the Licensee did not ensure that the resident or residents responisble party was given the required thirty (30) days notice to evict from the facility which poses an immediate Health, Safety and Personal Rights risk to residents in care.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2