415600904-4-25-2023-14-AS-KHOS-CSBKWS-20230530081626

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600904
Report Date: 04/25/2023
Date Signed: 04/25/2023 11:15:27 AM

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
06/29/2021 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210629133419

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:	0	CENSUS: 44	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jason Mullen and Mary Ann Lucero		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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- Facility has rodents
- Staff are not keeping resident's bathroom clean
- Staff do not respond to call button timely
- Unsafe food handling
- Client treated disrespectfully by staff
- Staff unable to communicate with client(s) in English

NOTE: This facility license is no longer valid--see #415601112 for current licensed facility

INVESTIGATION FINDINGS:

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Based on observations made on 7/8/21 during initial complaint visit, review of client and facility records, and interviews with staff and witnesses, these allegations are determined to be unsubstantiated.

Facility has contract in place for monthly pest inspections. Interior and exterior rodent traps are set checked and reset. Records of service calls in April and May 2021 state that "no rodent activity noted," and "no findings noted during service."

According to staff schedule, a housekeeper works 6 days a week. They are responsible for daily cleaning of all client bathrooms and fixing the beds, including cleaning up spills and accidents. In addtion, caregivers tidy up rooms, fold, wash, and hang clothes up on a daily basis.

Each of the 24 rooms was equipped with an emergency call system that is accessed in the bedroom and another in the bathroom. When activated, a light is illuminated at the main panel located just outside of the administration office on the first floor, as well as a light above each room door. In addition, a loud auditory alarm is activated when someone has pulled the cord in their bedroom or bathroom. There is another smaller unit/panel on the second floor which also illuminates a button corresponding to a room number. The system does not record when a resident activates the call system, nor when staff respond.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

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-20210629133419

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: MILLBRAE ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 415600904
	VISIT DATE: 04/25/2023

NARRATIVE

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Emergency call system has since been upgraded and observations made during previous visit no longer exist. In October 2022, Smart Caregiver emergency call system was installed. This is a wireless pendant call system that consists of a main panel at the first floor nurses station, pagers for care staff, and wall mounted call buttons in bathrooms and pendants for each resident. There is no record/log of calls or response times in the current system nor the system that was replaced.

During kitchen inspection on 7/8/21, kitchen staff were observed wearing masks, closed toe shoes, and hair nets. Serv Safe California Food Handler Certificates of Achievement were current. Head cook stated that all kitchen staff wear gloves, masks and hair nets when working in the kitchen.

As per staff training records, personal rights training was completed in 2019 and 2021 for 10 staff.

LPA met with housekeeping staff during initial visit, who was unable to comprehend simple questions. LPA was advised that this staff has a hearing deficit. Other staff interviewed were able to communicate effectively in English.

Although these allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 04/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2023

LIC9099 (FAS) - (06/04)

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