415600904-9-10-2020-14-AS-KHOS-BULNRT-20201021104202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600904
Report Date: 09/10/2020
Date Signed: 09/10/2020 01:56:40 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
10/31/2019 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20191031133035

FACILITY NAME:	MILLBRAE ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	415600904
ADMINISTRATOR:	LUCERO, MARY ANN		FACILITY TYPE:	740
ADDRESS:	1001 HEMLOCK AVE		TELEPHONE:	(650) 689-5776
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY:	48	CENSUS: 38	DATE:	09/10/2020
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Mary Ann Lucero, Administrator		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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- Illegal Eviction
- Facility staff failed to seek medical attention for the resident in a timely manner
- Facility staff failed to meet the resident's needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza conducted an unannounced subsequent virtual complaint inspection via facetime on the above allegations. LPA Raygoza stated purpose of virtual visit to Administrator, Mary Ann Lucero.

- Illegal Eviction. Based on the interviews with San Mateo County staff members, Ombudsman and facility staff, 4 out of 4 interviews implicated no illegal eviction rather a meeting and intervention for a higher level of care placement for R1. On 8/27/20 There was a collaborative meeting held with various staff members from San Mateo County, Social Worker, Psychiatrist, family, Ombudsman and facility staff members for a placement for R1. Therefore, the allegation was UNSUBSTANTIATED.

Cont'd on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

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-20191031133035

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: MILLBRAE ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 415600904
	VISIT DATE: 09/10/2020

NARRATIVE

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- Facility staff failed to seek medical attention for the resident in a timely manner. Based on record review of incident Reports, Physician Report, Medication records and Assessment Needs and Services plan there was medical attention sought out and a meeting held for intervention in a timely manner. Therefore, the allegation was UNSUBSTANTIATED.

- Facility staff failed to meet the resident's needs. Based on Interviews of staff, Ombudsman, Behavioral Health and Recovery Services Coordinator, Intense case Manager and Mental Health Clinician Supervisor, R1's needs were met and a meeting held for intervention in a timely manner. Therefore, the allegation was UNSUBSTANTIATED.

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

This report was reviewed and discussed with MaryAnn Lucero, Administrator.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2020

LIC9099 (FAS) - (06/04)

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