415600988-10-11-2023-14-AS-KHOS-CWNLXN-20231016090858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600988
Report Date: 10/11/2023
Date Signed: 10/11/2023 01:22:56 PM

Substantiated

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
08/23/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230823130422

FACILITY NAME:	MARIAH'S GARDEN HOME CARE		FACILITY NUMBER:	415600988
ADMINISTRATOR:	ZEPEDA, MARIE D		FACILITY TYPE:	740
ADDRESS:	1910 CRESTWOOD DRIVE		TELEPHONE:	(650) 307-7925
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Administrator, Maria Zepeda		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff does not ensure residents have no access to knives.
Staff does not ensure kitchen floor is clean.
Staff does not ensure food is properly stored.

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

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 6

Control Number 14-AS-20230823130422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAH'S GARDEN HOME CARE	FACILITY NUMBER: 415600988
	VISIT DATE: 10/11/2023

NARRATIVE

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Regarding to allegation of- staff does not ensure kitchen floor is clean, the reporting party stated that the kitchen was filthy.

During LPA's visit on August 29, 2023, LPA observed the kitchen floor in between the medication cabinet and the food cart was filled with brown and white particles, and the stairs to the garage appeared to be black in the middle and sticky. These observations were acknowledged by the administrator.

After the investigation, this allegation is deemed to be substantiated and the deficiency was issued on August 29, 2023 on LIC 809 and LIC 809D reports. Facility has submitted a copy of the plan of correction and it was reviewed and approved by CCL.

Regarding to allegation of staff does not ensure food is properly stored, the reporting party stated that opened food condiments, such as mayonnaise, hot sauce and other items were not refrigerated, vegetables on the floor, and etc.

During LPA's visit on August 29. 2023, LPA did not observe the observations that were reported by the reporting party, however, based on the photos provided by the reporting party, it revealed that fruits and vegetables were placed on the floor, and opened food condiments were stored inappropriately.

After the investigation, this allegation is deemed to be substantiated.

Based on interviews, record reviews and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 14-AS-20230823130422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAH'S GARDEN HOME CARE	FACILITY NUMBER: 415600988
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/12/2023 Section Cited CCR 87555(b)(8)	1 2 3 4 5 6 7	87555 General Food Service Requirements..(b)The following food service requirements shall apply:..8) All food shall be of good quality. This requirement is not met as evidenced by open food condiments	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure food is in good quality and properly stored at all times. The administrator/licensee will submit a copy of the plan to CCL by 10/12/2023.
	8 9 10 11 12 13 14	were stored in appropriately and fruits and vegetables were stored on the floor which poses an immediately health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

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
08/23/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230823130422

FACILITY NAME:	MARIAH'S GARDEN HOME CARE		FACILITY NUMBER:	415600988
ADMINISTRATOR:	ZEPEDA, MARIE D		FACILITY TYPE:	740
ADDRESS:	1910 CRESTWOOD DRIVE		TELEPHONE:	(650) 307-7925
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Administrator, Maria Zepeda		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff leave residents unsupervised while in care.

INVESTIGATION FINDINGS:

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On October 11, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the findings. LPA met with administrator and explained the purpose of today's visit.

Regarding to allegation of - staff leave residents unsupervised while in care, the reporting party stated when he/she arrived at the facility, he/she was greeted by a resident #1 (R1) who stated that the administrator was at the house next door. After the reporting party entered the facility, he/she was approached by resident #2 (R2) who also stated that the administrator was probably at the house next door.

As part of the investigation, LPA interviewed the administrator, and responsible parties.

The administrator denied the allegation and stated that he/she was downstair in the garage doing resident's laundry when an unidentified male arrived at the facility.

LPA interviewed 3 responsible parties and all of them reported that there was always staff at the facility whenever they visited their residents and one of them has known the facility for 4 years and reported that sometimes the administrator was at the house next door however there was always staff at the facility.

Based on interviews, 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 administrator and a copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 6

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
08/23/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230823130422

FACILITY NAME:	MARIAH'S GARDEN HOME CARE		FACILITY NUMBER:	415600988
ADMINISTRATOR:	ZEPEDA, MARIE D		FACILITY TYPE:	740
ADDRESS:	1910 CRESTWOOD DRIVE		TELEPHONE:	(650) 307-7925
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	10/11/2023
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Administrator, Maria Zepeda		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff did not cooperate with Ombudsman Representative.

INVESTIGATION FINDINGS:

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On October 11, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the findings. LPA met with administrator and explained the purpose of today's visit.

Regarding to allegation of - staff did not cooperate with Ombudsman Representative, the reporting party alleged that the Ombudsman was not able to complete the facility visit as there no staff at the facility and when the Ombudsman left the facility, a male adult from the house next door approached the Ombudsman and asked the Ombudsman to move the car out of the driveway. The Ombudsman identified him/herself and explained the purpose of the visit, but the male adult continued to be adamant of having the Ombudsman to park somewhere else.

As part of the investigation, LPA interviewed the administrator who stated that during the incident she was in the garage doing resident's laundry and when she heard the commotion and came outside of the facility, the Ombudsman had already left. In addition, the administrator stated that the male adult is not a staff member at the facility, therefore, he would not be able to provide any assistance with the Ombudsman's request.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 14-AS-20230823130422

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARIAH'S GARDEN HOME CARE	FACILITY NUMBER: 415600988
	VISIT DATE: 10/11/2023

NARRATIVE

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According to the male adult, on the day of the incident, there was an unidentified male parked in his driveway so he asked the person to park somewhere else as there was a deliver coming for the facility and the driveway needed to be cleared for the delivery truck. However, this person refused to move initially but eventually did.

In regards to the Ombudsman's requests, the male adult stated that he was not a staff at the facility, therefore, he did not have any authorities to provide any information to the Ombudsman.

LPA checked facility's association list and this adult male was not associated with the facility.

After the investigation, this allegation is deemed to be unfounded as this male adult is not a staff and he was not able to cooperate with the Ombudsman's request.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report was discussed and a copy of this report is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2023

LIC9099 (FAS) - (06/04)

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