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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 05/14/2024
Date Signed: 05/14/2024 04:26:42 PM

Unfounded


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
05/10/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240510114244
FACILITY NAME:PENINSULA REFLECTIONSFACILITY NUMBER:
415600976
ADMINISTRATOR:ANNA ALLASFACILITY TYPE:
740
ADDRESS:205 COLLINS AVETELEPHONE:
(650) 731-4670
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY:57CENSUS: 45DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator - Anna AllasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Facility staff are attempting to illegally evict resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/14/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with the administrator Anna Allas and explained the purpose of today's visit.

During the investigation LPA conducted interviews and reviewed pertinent documents regarding the resident's admission agreement and status at the facility. According to documentation reviewed show that the resident was not formally evicted by the facility until 05/13/2024 with an formal eviction notice. The resident is under respite services under contract with him/her hospital. The contract reviewed states that the contract is set to expire on 05/13/2024 and also advised on the initiation of sending him/her to the hospital to continue services due to the expiration of the contract. The facility did not initiate the eviction. Additionally it was found that the hospital the resident is under respite contract with discontinued the refills so the resident can utilize the insurance plan with San Francisco. The facility only initiated emergency services in order for the resident to receive the medication via hospital emergency room out of precaution due to the resident refusing to pay for the medication himself/herself. It was not to evict per interviews. This allegation is unfounded.

This agency has investigated the complaint alleging: Facility staff are attempting to illegally evict resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with administrator. Copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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 2
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
05/10/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240510114244

FACILITY NAME:PENINSULA REFLECTIONSFACILITY NUMBER:
415600976
ADMINISTRATOR:ANNA ALLASFACILITY TYPE:
740
ADDRESS:205 COLLINS AVETELEPHONE:
(650) 731-4670
CITY:COLMASTATE: CAZIP CODE:
94014
CAPACITY:57CENSUS: 45DATE:
05/14/2024
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Administrator - Anna AllasTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Facility staff did not properly supervise residents resulting in altercation between residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 05/14/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with the admininstrator Anna Allas and explained the purpose of today's visit.

During the investigaiton LPA conducted interviews and reviewed pertinent documents. Allegation details and interviews conflict with one another. The incident that allegedly happened on 04/02/2024 was reported to the department on 04/10/2024 via incident report. The allegation details reported do not reflect what happened via interviews conducted with staff. No staff heard the resident call for help and neither was a call button pressed. What happened in the room cannot be proven besides what was initially said to staff when police arrived with out facitliy knowledge. The resident told the staff a different story on that day versus what was reported to the Department as part of the allegation details. Due to the conflicting information and details received this allegation is 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2024
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 2