415600976-3-17-2021-14-AS-KHOS-BZLJCU-20210330065630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 03/17/2021
Date Signed: 03/17/2021 03:26:46 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
07/28/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200728142349

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: 40	DATE:	03/17/2021
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Anna Allas, Administrator		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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- Resident developed pressure injuries while in care
- Illegal eviction

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza made a subsequent complaint visit via Virtual Facetime with Administrator, Anna Allas. LPA Raygoza stated purpose of visit.

- Resident developed pressure injuries while in care. R1 had previous leg wound when admitted to facility. Facility developed plan of care for R1 and takes preventative measures to address ongoing wound care for stabilizing. Based on Physician report with history of leg wound and treatment plans in place to address wound for treatment. R1 went to emergency and Skilled Nurse Facility and returned to facility with Wound Care 3x a week. R1 is currently having clinic care once a week. Therefore, the allegation was deemed unsubstantiated.
- Illegal eviction. Based on no eviction notice given to Resident, Jose Sagastume. Based on interviews with Ombudsman and staff, R1 was sent to hospital and due to higher level of care went to a Skilled Nurse Facility. During recovering 8/13/20, R1 was able to return to facility with Home Healthcare visits 3x a week for wound care and Plan of Care for treatment plan as of 8/1/20. Therefore, the allegation was deemed Unsubstantiated.

Although the allegations 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 allegations are deemed unsubstantiated at this time.

This report was reviewed, discussed and a copy given to Anna Allas, Administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2021

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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