415600735-10-12-2023-14-AS-KHOS-CX4MW9-20231030095758

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600735
Report Date: 10/06/2023
Date Signed: 10/12/2023 04:09:32 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
09/26/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230926093040

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: 5	DATE:	10/06/2023
		UNANNOUNCED	TIME BEGAN:	03:56 PM
MET WITH:	Irene Mehta		TIME COMPLETED:	06:30 PM

ALLEGATION(S):

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Staff do not treat resident with dignity

INVESTIGATION FINDINGS:

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Amended Report (Allegation not placed)

On 10/6/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Irene Mehta and explained the purpose of today's visit.

Regarding the allegation that staff do not treat resident with dignity. Reporting party (RP) stated that the facility staff are too aggressive with resident (R1) and are bullying her.

During the investigation, LPA interviewed staff members. Four out of four stated that they all help residents at the facility when they call for assistance. There are occasions where staff tell R1 to wait a bit because they are still helping another resident. Staff stated that they haven’t been aggressive to R1 and any other residents and they don’t remember a time that they have bullied the residents.

Unsubstantiated

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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

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-20230926093040

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: 10/06/2023

NARRATIVE

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LPA also interviewed three residents, all residents stated that they are well taken care of in the facility. Residents also said that the caregivers are really nice and that they all feel very safe here. Residents also stated that whenever they ring the bell, staff help them right away. They don’t remember staff being aggressive to them or any staff member bullying them.

Therefore, based on the interviews conducted and information collected, the allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed 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: 10/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2023

LIC9099 (FAS) - (06/04)

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