415600976-1-31-2023-14-AS-KHOS-CQCLDW-20230328084037

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600976
Report Date: 01/31/2023
Date Signed: 01/31/2023 03:48:42 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
10/21/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221021124700

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:	DATE:	01/31/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Kathy Nguyen		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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- Resident contracted lice while in care
- Facility does not inform resident's responsible party of changes in resident's condition
- Facility staff mismanaged resident's medications

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an un-announced complaint investigaton visit to deliver the findings for the allegations listed above. LPA spoke to Wellness Director Kathy Nguyen and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews, reviewed records of R1, and made observations of the resident. It cannot be determined the source of the lice. No other residents or staff had lice before or after R1. There were not many visitors to R1. LPA could not determine the source. In regards to informing the responsible party of changes in resident's condition, and medications mismanagement, LPA could not determine if either are true. Facility says updates and informing of the the responsibily pary did happen at all times. In regards to medications, there was a flow of information issue between doctor and responsible party with the facility that disrupted or caused issues with medication information being shared with the facility. 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. No citations issued. Report is reviewed with Kathy Nguyen.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2023

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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