415600735-7-28-2023-14-AS-CSMH-CUJPUG-20230809113732

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600735
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:52:04 PM

Unfounded

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
07/21/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20230721170557

FACILITY NAME:	DOUBLE HAPPINESS CARE HOME		FACILITY NUMBER:	415600735
ADMINISTRATOR:	LAU, FLORDELIZA		FACILITY TYPE:	740
ADDRESS:	859 CAMARITAS CIRCLE		TELEPHONE:	(650) 993-4018
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS:	DATE:	07/28/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:			TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Facility doesn't allow visitors for the residents

INVESTIGATION FINDINGS:

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On 7/28/23, Licensing Program Analysts (LPAs) Grace Donato & Jaime Vado arrived unannounced to conduct 10-day complaint visit. LPAs met Designated Responsible person Irene Mehta and explained the purpose of the visit.

Regarding the allegation that the facility doesn't allow visitors for the residents, according to the reporting party (RP), that residents are not being allowed visitors in the facility. RP mentioned that the current person running the facility are not allowing visitors to residents. RP also stated that he/she is being harrased by the same person whenever he/she visits the resident.

During the investigation, LPAs reviewed reviewed and obtained copies of visitors log and interviewed staff.

Based on this record review, visitors are able to come in and visit the residents in care during reasonable hours. Visitors sign in with date, time, who they visited.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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-20230721170557

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: DOUBLE HAPPINESS CARE HOME	FACILITY NUMBER: 415600735
	VISIT DATE: 07/28/2023

NARRATIVE

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Based on interviews, both care staff confirmed that all visitors are allowed in the facility. No specific guests or family members are not being allowed to enter the facility ad visit the residents.

Therefore, based on the interviews conducted, documents reviewed, and information collected, the allegation that the facility doesn't allow visitors for the residents UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Report is reviewed with Irene Mehta and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC9099 (FAS) - (06/04)

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