415600988-8-10-2020-14-AS-BCHN-BSMUED-20200819153056

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600988
Report Date: 08/10/2020
Date Signed: 08/10/2020 01:33:55 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
04/28/2020 and conducted by Evaluator Michael Garcia

COMPLAINT CONTROL NUMBER: 14-AS-20200428163148

FACILITY NAME:	MARIAH'S GARDEN HOME CARE		FACILITY NUMBER:	415600988
ADMINISTRATOR:	ZEPEDA, MARIE D		FACILITY TYPE:	740
ADDRESS:	1910 CRESTWOOD DRIVE		TELEPHONE:	(650) 797-7951
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	08/10/2020
		UNANNOUNCED	TIME BEGAN:	08:13 AM
MET WITH:	Maria Zepeda		TIME COMPLETED:	11:10 AM

ALLEGATION(S):

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Staff not following posted menu.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Michael Garcia conducted a follow-up complaint investigation regarding the above allegation. Due to the COVID-19 pandemic, the investigation was conducted via telephone and video call. LPA telephoned the facility at 8:13am but no one was available to answer the phone. The mailbox was full. LPA was unable to leave a voice message. Maria called LPA back at 9:01am.

On this day, LPA inspected the food served for breakfast, inspected the facility’s food supplies, interviewed Resident #5 (R5), Resident #6 (R6) and reinterviewed Resident #1 (R1). Photos of food supplies taken. Copies of resident and staff rosters obtained.

CONTINUE ON NEXT PAGE...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael Garcia	TELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

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-20200428163148

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: MARIAH'S GARDEN HOME CARE	FACILITY NUMBER: 415600988
	VISIT DATE: 08/10/2020

NARRATIVE

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According to staff interviews, Maria stated she follows a sample menu and adjust it based on the resident’s preference during admission.

According to resident interviews, five (5) residents described that the facility serves breakfast, lunch and dinner. Residents described the following being served at the facility:
- Breakfast: cereals, egg omelet, scrambled eggs, toast bread, baloney, yogurt, coffee, lemonade.
- Lunch: chicken, baloney, rice, beans, spinach, fudge, baby cakes.
- Dinner: cheese/salami pizza, chicken pot pie, veggie/chicken tacos, burrito, iced tea.

During the initial investigation, LPA observed salmon, spinach salad, and fried rice being cooked for lunch. Today, LPA observed scrambled eggs and ham sandwich with cheese for breakfast. The facility was observed with sufficient 2-day perishable and 7-day non-perishable food supplies throughout the investigation. The meals served matches the facility’s sample menu throughout the investigation.

Based on administrator’s statement, resident interviews, record reviews and LPA’s observation, the allegation was deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

Report was discussed with Maria at the end of the investigation. An electronic copy of the report was emailed to Maria for signature.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael Garcia	TELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2020

LIC9099 (FAS) - (06/04)

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