415600874-1-25-2023-14-AS-KHOS-CPNPRV-20230306103322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600874
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:25:47 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
12/23/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221223155140

FACILITY NAME:	BROOKDALE REDWOOD CITY		FACILITY NUMBER:	415600874
ADMINISTRATOR:	MONICA CERON TAPIA		FACILITY TYPE:	740
ADDRESS:	485 WOODSIDE RD		TELEPHONE:	(650) 366-3900
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	130	CENSUS: 72	DATE:	01/25/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Monica Ceron Tapia		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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- Resident illegally evicted

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegations. LPA met with the executive director Monica Tapia and explianed purpose of today's visit.

During the course of the investigation LPA condducted interviews and reviewed the eviction notice provided to the resident. Upon review of the eviction notice, as well as the resident's physician's report, and the facility assessments/reappraisals show that the only basis of eviction states the fact that the resident having dementia is the primary reason. The physicians report (LIC602) and assessment do not state other reasons for eviction. This allegation is substantiated.

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. Report is reveiwed with executive director Monica Tapia.

Substantiated

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: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

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-20221223155140

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: BROOKDALE REDWOOD CITY	FACILITY NUMBER: 415600874
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/25/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/31/2023 Section Cited CCR 87224(a)(4)	1 2 3 4 5 6 7	Eviction Procedures - If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted pursuant to Section 87463, and the licensee and the person who performs the reappraisal believe that the facility is not appropriate for the resident.	1 2 3 4 5 6 7	Facility shall correct and resubmit a proper eviction notice that meet all the criteria to support the basis of eviction. A new LIC602 and reappraisal shall be received.
	8 9 10 11 12 13 14	Regulation is not met as evicenced by: upon review of the eviction notice the basis for eviction requires more information to support the reason for eviction. The reappraisal does not state or support basis for eviction as well as it does not identify any new behaviors or conditions for eviction. The LIC602 shows that the resident is able to leave on his own, able to communicate needs, and other items suggesting independence.	8 9 10 11 12 13 14	This POC shall be received by the Department by due date.
	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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2023

LIC9099 (FAS) - (06/04)

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