415600904-3-19-2021-14-AS-KHOS-BZLJJU-20210330070608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600904
Report Date: 03/19/2021
Date Signed: 03/19/2021 11:28:42 AM

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
09/01/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200901100615

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: 39	DATE:	03/19/2021
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	MaryAnn Lucero, Administrator		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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- Staff did not ensure resident had access to oxygen

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza conducted a virtual subsequent complaint visit via facetime with Administrator, Mary Ann Lucero. LPA Raygoza stated purpose of inspection visit regarding the above allegation.

- Staff did not ensure resident had access to oxygen. During the investigation the following came forth, there was an oxygen machine with mask at R1's disposal, which R1 was able to self administer. The mask part was worn and not as a snug fit as a new mask. Facility processed in a new mask order and the snug fit was able to present itself as a better fit. Staff had access to oxygen but the mask part was worn and a better snug fit was able to be remedied by a new mask. Therefore the allegation was deemed unsubstantiated.

Although the allegation 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 allegation is unsubstantiated at this time.

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

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: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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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