415600735-9-29-2023-14-AS-KHOS-CX4MWA-20231030095759

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600735
Report Date: 09/29/2023
Date Signed: 09/29/2023 06:07:52 PM

Substantiated

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:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Irene Mehta		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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9

Staff did not conduct a preadmission appraisal for resident prior to move-in

INVESTIGATION FINDINGS:

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On 09/29/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced 10-day complaint inspection. LPA met with Irene Mehta and explained the purpose of today's visit.

Regarding the allegation of staff did not conduct a preadmission appraisal for resident prior to move-in. Reporting party (RP) stated that an assessment was never completed with the resident (R1) before he/she moved in so they did not realize his/her needs.

LPA confirmed during an interview that staff wasn't able to conduct a personal interview and observation to meet R1 prior to admission. The preadmission was just discussed with the family member and a senior referreal agent. LPA also conducted a records review and was found out that some conditions are not stated but was only found out when R1 started living in the facility.

Based on interview and records review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed and copy of this report and the Appeal Rights are provided.

Substantiated

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: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/29/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/30/2023 Section Cited CCR 87457(a)	1 2 3 4 5 6 7	87457 Pre-Admission Appraisal - General (a) Prior to admission, the prospective resident and his/her responsible person, if any, shall be interviewed by the licensee or the employee responsible for facility admissions. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to submit a plan on how to address Pre Admission Appraisals for future residents. Licensee to submit by POC due date.
	8 9 10 11 12 13 14	Based on interview and record review, the licensee did not comply with the section cited above due to staff wasn't able to conduct a personal interview and observation to meet R1 prior to admission which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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:	09/29/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Irene Mehta		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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5
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7
8
9

Staff did not follow proper eviction procedures for resident

INVESTIGATION FINDINGS:

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13

This is an amended report for the visit on 9/29/23.

On 09/29/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced 10-day complaint inspection. LPA met with Irene Mehta and explained the purpose of today's visit.

Regarding the allegation of Staff did not follow proper eviction procedures for resident, RP stated that family member received a message that resident (R1) is going to be evicted.

LPA interviewed staff member and stated that a verbal eviction notice was given to the responsible party and facility will be sending the 30-day eviction notice. The resident wasn't evicted immediately.

Based on records review, facility submitted to Licensing an eviction letter that provides a 30-day notice and followed proper procedures regarding eviction.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report was discussed and a copy of this report is provided.

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: 09/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4