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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600966
Report Date: 07/17/2023
Date Signed: 07/17/2023 07:06:55 PM

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
01/27/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220127111946
FACILITY NAME:GEORGE ANNE HOMEFACILITY NUMBER:
415600966
ADMINISTRATOR:JOHNSON, MARIA LUFACILITY TYPE:
740
ADDRESS:849 N DELAWARE STREETTELEPHONE:
(650) 931-4741
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
07/17/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Maria JohnsonTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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- Staff handled resident in a rough manner
- Staff failed to feed resident properly
- Staff administered medication to resident without physician's approval
- Staff failed to meet resident’s needs
INVESTIGATION FINDINGS:
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Based on client records review and interviews with staff and witnesses, these allegations are determined to be unsubstantiated.

Client #1 was admitted to facility in December 2021 from the hospital after suffering 2 strokes; she was on hospice care and diagnosed with dementia. Her adjustment as a new resident was complicated due to her frustration; she exhibited adverse behaviors, which initially challenged staff. It could not be verified that staff handled client in a rough manner nor fed her improperly.
Client's behaviors prompted staff to seek MD intervention, including medication alternatives. There is no evidence that client was given medication prescribed to another client.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
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
01/27/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220127111946

FACILITY NAME:GEORGE ANNE HOMEFACILITY NUMBER:
415600966
ADMINISTRATOR:JOHNSON, MARIA LUFACILITY TYPE:
740
ADDRESS:849 N DELAWARE STREETTELEPHONE:
(650) 931-4741
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
07/17/2023
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Maria JohnsonTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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2
3
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9
- Staff made resident’s video without her consent
INVESTIGATION FINDINGS:
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13
Based on information reported by and obtained from facility staff and witnesses, this allegation is determined to be substantiated.

In January 2022, administrator video recorded client's behaviors on a cell phone and sent the recording to client's medical professional, seeking a medication change. Client's responsible party did not provide written consent to allow this.

The preponderance of evidence standard has been met. Deficiency of the California Code of Regulations, Title 22 is cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20220127111946
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: GEORGE ANNE HOME
FACILITY NUMBER: 415600966
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2023
Section Cited
CCR
87468.2(a)(2)
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ADDITIONAL PERSONAL RIGHTS
In addition to the rights listed in 87468.1, residents in privately operated RCFEs shall have the personal right to have their records and personal information remain confidential and to approve their release, except as authorized by law.
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Plan of correction to be sent to CCLD BY DUE DATE
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This requirement was not met, as a video recording was made by staff and sent to client's NP without consent of client or responsible party. Licensee failed to protect confidentiality of client's personal information, which posed a potential personal rights risk to clients in care.
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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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3