415600976-9-2-2021-14-AS-KHOS-C6MKRW-20210907080838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 09/02/2021
Date Signed: 09/02/2021 04:46:01 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
08/23/2021 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210823084459

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: 42	DATE:	09/02/2021
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Anna Allas		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility staff did not prevent resident from leaving the facility
Illegal Eviction

INVESTIGATION FINDINGS:

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On this day at 1600hrs, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to conduct the initial investigation visit and deliver findings for the allegations received. LPA met with administrator Anna Allas and explained purpose of today's visit.

During the course of the investigation LPA conducted interviews and reviewed pertinent resident documents. According to facility staff interviewed, they saw and followed the resident when she left the facilty. They attempted to redirect the resident back to the facility but the local police department was called when she would not return. They stayed with the resident until police arrived. According to the facilty the intent was for the resident to return. Facility requested additional care and medication adjustment but was notified that the resident was going to be relocated by her placement team. Facility insisted the intent was for the return of the resident and not a relocation. LPA did not receive any return calls from complainant regarding the allegations and was unable to conduct interviews with the complainant. These allegations are unsubstatiated.

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 discussed and reviewed with administrator.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2021

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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