415600868-4-4-2023-14-AS-KHOS-CQRKBN-20230410074546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600868
Report Date: 04/04/2023
Date Signed: 04/04/2023 03:09:30 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
12/28/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221228162303

FACILITY NAME:	PALM ASSISTED LIVING LLC		FACILITY NUMBER:	415600868
ADMINISTRATOR:	RENUKA GANDHI		FACILITY TYPE:	740
ADDRESS:	2818 TIBURON WAY		TELEPHONE:	(650) 651-7031
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	6	CENSUS: 0	DATE:	04/04/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Renuka Gandhi		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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- Staff did not allow the Long Term Care Ombudsman to finish a visit with a resident in care
- Staff verbally abused Long Term Care Ombudsman in the presence of resident
- Facility did not ensure resident is provided a safe environment

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations received. LPA met with licensee Renuka Gandhi and explained the purpose of todays visit.

During the course of the investigation LPA conducted interviews with parties involved. LPA could not determine if the allegations took place as described as this happend over an extended period of time. It is one parties word over another. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2023

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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