415600658-4-16-2024-14-AS-KHOS-D4KP3T-20240422105805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600658
Report Date: 04/15/2024
Date Signed: 04/16/2024 08:19:44 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/01/2024 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240301133804

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: 11	DATE:	04/15/2024
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Matthew Montilla		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Resident was financially abused while in care
Resident personal belongings are missing
Staff did not treat resident with respect

INVESTIGATION FINDINGS:

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On 4/15/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Assitant Administrator Matthew Montilla and explained the purpose of today's visit.

Regarding the allegation of Resident was financially abused while in care, Reporting Party (RP) stated that someone financially abused them at the facility by making purchases through Amazon, Uber Eats, and other platforms using their debit card.

LPA interviewed three staff members. Two staff members (S1 & S2) mentioned that R1 has full control over their own finances and uses own phone to order. All staff stated that R1 likes to order from Amazon, Uber Eats & Doordash.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

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-20240301133804

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DAMENIK'S HOME	FACILITY NUMBER: 415600658
	VISIT DATE: 04/15/2024

NARRATIVE

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Regarding the allegation of resident personal belongings are missing, RP stated that many of their personal belongings are still missing, including jackets, shirts, electronics, a cell phone, a portable battery, a charger, cords, his driver’s license, a debit card, documents, and more.

S1 mentioned that R1s belongings were picked up by family members. RP also stated that it was given to family members. LPA was able to interview one family member (F1) and it was confirmed that they were able to pick up R1s belongings that was already packed by the facility in storage boxes. These boxes were placed in R1s house. F1 also mentioned that the items that R1 were looking for were the ones they were wearing when an ambulance transported them to the hospital. It may or may not have been lost in transit when R1 was transported to a skilled nursing facility.

Regarding the allegation of staff did not treat resident with respect, RP reported calling the facility and speaking to a staff member (S2) to inquire about missing personal belongings. However, S2 told the RP not to call the facility again.

LPA interviewed S2 and stated that they said no words to R1.

Based on interviews & records review the department has determined that that these allegations are false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

No deficiencies being cited today. Report is reviewed and copy is provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 04/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024

LIC9099 (FAS) - (06/04)

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