415600976-2-7-2024-14-AS-KHOS-D2LK2P-20240219063124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 02/07/2024
Date Signed: 02/07/2024 01:32:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
11/13/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231113115810

FACILITY NAME:	PENINSULA REFLECTIONS		FACILITY NUMBER:	415600976
ADMINISTRATOR:	ANNA ALLAS		FACILITY TYPE:	740
ADDRESS:	205 COLLINS AVE		TELEPHONE:	(650) 731-4670
CITY:	COLMA	STATE: CA	ZIP CODE:	94014
CAPACITY:	57	CENSUS: 45	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	LIfe enrichment director - Nancy Medina		TIME COMPLETED:	01:35 PM

ALLEGATION(S):

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- Staff did not prevent another resident from entering resident's room
- Staff do not respond to residents' call buttons in timely manner
- Staff are unable to communicate with residents due to a language barrier
- Staff do not prevent another resident from waking resident
- Staff put a resident in residents room that is not compatable with resident.

INVESTIGATION FINDINGS:

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On 02/07/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Nancy Medina and explained the purpose of today's visit.

During the investigation LPA conducted interviews and reviewed resident documents. The resident entering the room of R1 had dementia. This facility is an all dementia facility and rooms do have locks that are accessible by staff via key, but for safety reasons staff do not lock doors. As a result of the resident entering the room of R1, staff began to close and lock the door of R1 as requested by R1 since R1 does not have dementia. Call button requests made by R1 were met to the best of the facilities abilities as there are cargivers assigened to groups of residents. Staff responded accordingly based on operational needs and requirements at the times the requests were made. A delay may have incurred, but not based in intent, but staff availability to respond as staff do help other residents in care. R1 does not have one on one caregiving.

Continued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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-20231113115810

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA REFLECTIONS	FACILITY NUMBER: 415600976
	VISIT DATE: 02/07/2024

NARRATIVE

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Page 2 - LIC9099

Staff in the facility are able to communicate to residents as necessary. Some staff do have difficulty but not to the point of not understanding. Those staff with a language barrier, do have resources such as other staff to assist in translation, and have the ability to communicate using translation devices. R1's room mate was diagnosed with dementia and would wake up at random hours during the night due to diagnosis such as sundowning. As a result, the facility moved the room mate and provided R1 with a private room despite only paying for a single bed, not a double, and was able to stay in the room for the duration of their time of the facility. The room mate was deemed compatible at the time of assessmentsm but when the room mates behavior changed, the facility moved the room mate to a better compatible room which provided R1 with their own room. The facility attempted to meet the needs of R1 at all times and made adjustments where needed. The facility communicated with R1 and the social worker of R1 to collaborate and continue to meet the needs and requests made by R1. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations 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 above allegations are unsubstantiated at this time.

Report is reviewed with Nancy.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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