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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600867
Report Date: 04/22/2020
Date Signed: 04/22/2020 02:34:32 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
12/24/2019 and conducted by Evaluator Sarena Keosavang
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20191224100635
FACILITY NAME:PENINSULA DEL REYFACILITY NUMBER:
415600867
ADMINISTRATOR:ALFREDO CRUZFACILITY TYPE:
740
ADDRESS:165 PIERCE STTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:156CENSUS: 92DATE:
04/22/2020
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Dillon Cagulada TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Director of Assisted Living does not spend an appropriate amount of time in the facility.
- Resident's needs are not met.
INVESTIGATION FINDINGS:
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On April 22, 2020, Licensing Program Analyst (LPA) Sarena Keosavang conducted an unannounced complaint investigation to issue final findings. LPA met with Executive Director, Dillon Cagulada, and disclosed the purpose of the investigation.
During the Department's course of investigation, the following information was obtained: facility staff interview, residents' interview, pertinent documents relevant to the investigation such as Director of Assisted Living’s Payroll.
Regarding the allegation, Director of Assisted Living (DOAL) does not spend an appropriate amount of time in the facility. Based on investigation conducted by the Department, which includes interviews and obtaining pertinent documents that is relevant to the investigation. LPA interviewed Complainant regarding the allegation. Complainant stated that DOAL is never at the facility. Complainant stated that staff is unable to get ahold of DOAL because she never answers her phone. Complainant stated when DOAL is contacted tells staff, “you deal with it.” LPA interviewed five staff and four residents at the facility. All five staff and a resident are concerned with the amount of time the DOAL is spending at the facility and it’s affecting the operational needs. Staff stated that they are constantly short on staff and they need help finding substitutes. Most of the staff that was interviewed by LPA stated, the DOAL is not at the facility as often as she should be. S1 stated that DOAL is supposed to work 5 days a week, but she’ll be at the facility only 3 days out of the week. S2 stated DOAL is never available to answer questions and is very hard to get a hold of. S3 stated DOAL has been missing a lot of work and calls out a lot.

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Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8899
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020
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-20191224100635
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: PENINSULA DEL REY
FACILITY NUMBER: 415600867
VISIT DATE: 04/22/2020
NARRATIVE
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LIC9099 - PAGE 2

S3 also stated that DOAL is only at the facility 1-2 days out of the week. LPA interviewed residents at the facility. R3 stated DOAL hasn’t worked a shift. Whenever the facility is short of staff usually in the past, prior Directors that used to work at the facility would fill in and help. R3 stated DOAL was not helping the staff fill in and work a shift when there is a shortage . LPA interviewed Executive Director, Dillon Cagulada, regarding DOAL not spending an appropriate amount of time at the facility that it’s affecting operation. Dillon Cagulada stated that staff is resistant to change directed from the new DOAL. When LPA asked Executive Director what the facility’s plan is when somebody calls in sick, Dillon stated they hired a staff coordination to help schedule and find substitutes and call whoever can fill in. Dillon stated that staff coordinator and DOAL can also fill in to help if needed. Dillion stated, “DOAL was filling in when caregivers were sick and called off.” Dillion stated, “Aileen is implementing new procedures which staff are resistant to such geographic assignments.” LPA interviewed DOAL and asked if DOAL has an Administrator’s certificate. DOAL stated she does not have an Administrator’s Certificate. DOAL’s payroll which stated how many hours worked from October 1, 2019 to March 1, 2020. According to the Payroll of DOAL obtained by LPA, it states DOAL’s biweekly hours worked at the facility. On December 1, 2020 to December 15, 2020, DOAL worked 70.67 hours at the facility. On January 1, 2020 to January 15, 2020, DOAL worked 78.67 hours at the facility. On February 1, 2020 to February 15, 2020, DOAL worked 86.67 hours at the facility. The payroll does not state if DOAL used sick leave hours which can be included in the total hours worked biweekly. According to Licensing's records, Dillon Cagulada is the administrator for Peninsula Del Rey and has an Administrator Certificate. Dillon Cagulada stated, he is physically at the facility for 40 or more hours and always on call every other hour after business hours including weekends. The Department has investigated the complaint of Director of Assisted Living (DOAL) does not spend an appropriate amount of time in the facility. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation may have happened or is valid, therefore the allegation is deemed UNSUBSTANTIATED.

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SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8899
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20191224100635
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: PENINSULA DEL REY
FACILITY NUMBER: 415600867
VISIT DATE: 04/22/2020
NARRATIVE
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LIC9099 - PAGE 3

Regarding the allegation, residents’ needs are not met. Based on investigation conducted by the Department, which includes interviews with five staff and four residents and obtained pertinent documents such as pendant call logs that is relevant to the investigation. LPA interviewed Complainant regarding the allegation. Complainant stated there is not enough staff to care for residents. Complainant stated when residents needs assistance, the residents would have to wait for about 45 minutes to an hour. LPA interviewed residents regarding staff and whether they were providing adequate care. When LPA asked R1 about the care provided by staff, she stated it was okay. LPA asked R1 about R1’s experience when calling for staff using the call pendant. R1 stated so many people live here usually the wait is not too long about half an hour. R1 stated if it’s too long of a wait R1 will call the front desk. If they don’t respond to R1's call, R1 will call responsible party to let them know. R1 stated usually in the morning staff is very busy. LPA interview R2, regarding R2’s experience when calling for staff’s assistance using pendant. R2 stated it’s very busy after dinner. It takes more time when it’s busy. When asked how often R2 uses the pendant, he said twice a day. LPA asked if R2 was satisfied with the response time, R2 said "yes, I am." R2 stated in general they’re doing their job. LPA interview R3 regarding the care provided by the staff. LPA asked if clients’ needs are being met, R3 said "yes." R3’s needs are being met, but others have to wait a long time for staff to respond to their call pendants. LPA interview R4 and asked about the care provided by staff. R4 said she has no complaints. When asked about R4’s experience when calling for staff using the call pendant, R4 said that staff response is okay and that they respond in a timely manner most of the time. On January 2, 2020, LPA requested for the facility’s Stanley Healthcare call pendant log that staff has been using to track residents’ calls for assistance. The call pendant log provides date and time residents call for assistance, description of what type of assistance was needed, apartment number, and time it took for staff to respond to the call. LPA reviewed the log pendant document and saw that most calls were being responded from 1-30 minutes. On January 1, 2020, there were two calls that took staff longer than 30 minutes to respond to resident’s pendant call. The Department has investigated the complaint of residents’ needs are not met. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation may have happened or is valid, therefore the allegation is deemed UNSUBSTANTIATED.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8899
LICENSING EVALUATOR NAME: Sarena KeosavangTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3