415600689-5-18-2023-14-AS-KHOS-CSHNGZ-20230605102758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600689
Report Date: 05/18/2023
Date Signed: 05/18/2023 04:04:40 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
01/12/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220112145721

FACILITY NAME:	STRATFORD, THE		FACILITY NUMBER:	415600689
ADMINISTRATOR:	CAMILLE CHRISTIE		FACILITY TYPE:	741
ADDRESS:	601 LAUREL AVE		TELEPHONE:	(650) 342-4106
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	96	CENSUS: 68	DATE:	05/18/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Camille Christie and Lori Wolfe		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Staff ordered medication without authorization approval

- Resident was forced to produce screening sample against their will

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

LPA Jeung met with administrator and RN/resident care director and reviewed file for former resident. Copies of medical correspondence and portions of Continuing Care Residence Agreement are provided.

Based on documents reviewed and interviews with staff, this allegation is determined to be unsubstantiated.

Former independent resident requested staff assistance because she experienced chronic redness, pain and itchiness on her abdomen which was present in 2019, according to facility notes. Staff contacted client's PCP and received MD orders for various powders and creams, which client maintained in her room.
Results of stool sample dated 4/30/20 as ordered by client's PCP are documented. According to facility RN, client was experiencing diarrhea and constipation, and PCP was consulted.

Although these allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2023

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 3