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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600769
Report Date: 12/09/2020
Date Signed: 02/24/2021 01:39:10 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/08/2020 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201208154245
FACILITY NAME:LYONS ELDERLY HOME LLCFACILITY NUMBER:
415600769
ADMINISTRATOR:JAVIER, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 556-1754
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 4DATE:
12/09/2020
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Josephine JavierTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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***Amended to reflect public report designation***

On December 9, 2020 at 1030 LPA Jaime Vado conducted an unannounced complaint
tele-inspection to investigate the allegation recieved. LPA spoke to licensee Josephine Javier.

During today's tele-inspection LPA interviewed the administrator regarding the allegation and the proposed closure on 12/31/2020. LPA received eviction notices dated on 11/15/2020. One letter was dated 11/15/2020 but post marked on 12/01/2020. The eviction notices reviewed should be in fact closure notices as they state the facility is closing. These notices do not meet the 60 closure notice requirements outlined in Health and Safety Code and lack the items requried in such notices. LPA discussed with the licensee that the notices do not meet the required closure notice criteria. It was also found that notice was not provided to CCLD and local Long Term Care Ombudsman (LTCO) of the closure. Family of the residents provided notice to LTCO who then reported to CCLD.

Continued on next page...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
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
Control Number 14-AS-20201208154245
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: LYONS ELDERLY HOME LLC
FACILITY NUMBER: 415600769
VISIT DATE: 12/09/2020
NARRATIVE
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Page 2: LIC9099

LPA requested that the licensee submit to LPA via fax what was provided to the families and representatives of the residents. She agreed to do so. LPA also notified her that she will need to submit a corrected 60 day closure notice that meets the criteria required for department approval.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20201208154245
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: LYONS ELDERLY HOME LLC
FACILITY NUMBER: 415600769
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2020
Section Cited
CCR
87224(5)(A)
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Eviction Procedures - The licensee may, upon no less than sixty (60) days written notice, evict a resident due to change of use of the facility.
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87224(5)(A).
Licensee shall provided an updated 60 day closure notice with appropriate information and proposed closure date. Closure date will be reflected from date of completed 60 day notice.
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This requirement has not been met as evidenced by: Licensee provided eviction notices dated 11/15/2020 to facility residents with a facility closure date of 12/31/2020. This does not meet 60 day notice requirement.
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Type B
12/16/2020
Section Cited
CCR
87224(f)
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Eviction Procedures. A written report of any eviction shall be sent to the licensing agency within five (5) days.
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87224(f). Licensee shall provide proper notice to CCLD regarding facility closure in written form.
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This requirement has not been met as evidenced by: Licensee did not notify the Department of her intent to close the facility within 5 days. The Department learned of the intent to close via a report from county long term care ombudsman not from the licensee. This does not meet the 5 day requirement.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3