415600658-6-20-2022-14-AS-KHOS-CG8K32-20220711073201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600658
Report Date: 06/20/2022
Date Signed: 06/20/2022 01:35:37 PM

Unsubstantiated

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
04/05/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220405124343

FACILITY NAME:	DAMENIK'S HOME		FACILITY NUMBER:	415600658
ADMINISTRATOR:	MONTILLA, DANILO F.		FACILITY TYPE:	740
ADDRESS:	851 BADEN AVENUE		TELEPHONE:	(650) 827-1100
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	15	CENSUS: 14	DATE:	06/20/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Asst. Administrator, Matthew Montilla		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility has pests.
Facility staff do not follow universal (hand washing) precautions

INVESTIGATION FINDINGS:

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On June 20, 2022 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of this complaint investigation. LPA Han met with the assistant administrator and explained the purpose of the visit.

Regarding to allegation of facility has pests- there is no additional information forthcoming from the reporting party. During the initial reporting, the reporting party stated that some other family members observed pests and rodents in the kitchen.

During LPA's 10-day complaint inspection, LPA toured the kitchen and looked behind the garbage cans and appliances and did not observe any pests and rodents. LPA also toured resident's rooms, living room, dining room, and bathroom and did not observe any pests and rodents. In addition, LPA interviewed 3 resident and all of them reported that they have never seen any pests and rodents at the facility and in their rooms. Furthermore, LPA interviewed the administrator and the assistant administrator and both of them denied the allegation. Based on observation and interviews during the course of the investigation, this allegation is unsubstantiated.

Regarding the allegation of - staff do not follow universal (hand washing) precautions, there is no additional information forthcoming from the reporting party.

During the investigation, LPA interviewed the assistant administrator who denied the allegation and stated that all facility staff were trained on proper hand washing precautions. LPA interviewed 2 caregivers and both of them were able to articulate proper hand-washing techniques and stated that they were trained by San Mateo Public Health Department on proper hand-washing techniques. In addition, LPA interviewed 3 residents and all of them validated that they have observed staff washing their hands. Furthermore, LPA observed hand-washing instructions were posted by the hand-washing stations as a reminder to staff. Based on observation, and interviews during the course of the investigation, this allegation is unsubstantiated.

Although the allegations may have occurred or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are deemed UNSUBSTANTIATED.

This report is reviewed and discussed with the assistant administrator. A copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2022

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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