415600908-9-30-2021-14-AS-KHOS-C7QN6F-20211012101105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600908
Report Date: 09/30/2021
Date Signed: 09/30/2021 03:24:31 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
08/17/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210817094616

FACILITY NAME:	TARA HOUSE INC		FACILITY NUMBER:	415600908
ADMINISTRATOR:	SUNGA, DEYRA T.		FACILITY TYPE:	735
ADDRESS:	2545 TARA LANE		TELEPHONE:	(650) 794-9641
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS: 5	DATE:	09/30/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Caregiver, Miraflor Ferrer		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Resident sustained fracture while in care

INVESTIGATION FINDINGS:

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On 9/30/2021, Licensing Program Analysts (LPAs) Murial Han and Komal Charitra conducted an unannounced inspection to deliver the investigation findings. LPA Han and LPA Charitra was properly screen by the entrance. LPAs met with the caregiver, Miraflor Ferrer and explained the purpose of today's visit.

Regarding the allegation, resident sustained fracture while in care, LPA Han's investigation included interviewed staff, reviewed records and conducted observation. The staff members denied of sustaining any injuries while caring for Resident 1 (R1) that could have caused the fracture and they also reported that R1 did not sustain any falls. In addition, the staff stated that R1 is a dependent resident and required 2-person's assistance with the Activities of Daily Living which was observed by LPA Han during the visit that R1 was being cared for by 2 staff members.

The hospital's medical record did not indicated the cause of the injury and there is no information forthcoming from the resident. Therefore, this allegation is unsubstantiated as there is no evidence that the injury was sustained during care. However, during the course of the investigation, LPA observed that staff noted the change of R1's health condition but it was not reported until 48 hours later. This deficiency will be cited on LIC809D.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

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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Control Number 14-AS-20210817094616

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: TARA HOUSE INC	FACILITY NUMBER: 415600908
	VISIT DATE: 09/30/2021

NARRATIVE

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Based on observation, interviews and record reviews during the course of the investigation, the above allegation is unsubstantiated.

Although the above investigation 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 allegation is UNSUBSTANTIATED.

This report is reviewed and discussed the facility's caregiver and the Lead Staff, Maria Badioala over the phone. A copy is provided to the caregiver.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021

LIC9099 (FAS) - (06/04)

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