415601029-3-20-2021-14-AS-JMOS-BZFVCT-20210325161941

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601029
Report Date: 03/19/2021
Date Signed: 03/20/2021 08:58:32 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
07/17/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200717145517

FACILITY NAME:	GWENELLE'S HOME CARE		FACILITY NUMBER:	415601029
ADMINISTRATOR:	WONG, GWENDOLYN		FACILITY TYPE:	740
ADDRESS:	1424 HOPKINS AVE		TELEPHONE:	(650) 368-4419
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	6	CENSUS: 1	DATE:	03/19/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Gwen Wong		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Uncleared adults were working at the facility
Facility is dirty
Residents have deep pressure injuries
Food Service is inadequate
Staff do not keep updated medical records for residents
Resident's medication is given to other residents
Residents were over medicated

INVESTIGATION FINDINGS:

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***Amended document to reflect additional complaint details***

On March 19, 2020 at 1430 LPA Jaime Vado conducted an unannounced complaint
tele-inspection to deliver findings regarding the allegations received. LPA spoke to administrator/licensee GWEN WONG.

During the course of the investigation LPA conducted tele-inspections to make observations within the facility, review facility records, and medications. Dirty floors were not observed. Resident records and medication records are both observed and reviewed as in place and accurate. No inconsistancies were found in medication administration of any resident medication being given to another resident. Resident with presssure injury was cared for by hospice per documentation reviewed. Facility associations staff associations are reviewed and staff are associated. LPA observed facility food supplies. Multiple refrigerator/freezers observed and canned goods are in place. Per licensee statement, "the allegations came from an ex employee's disgruntled husband". LPA attempted to contact complainant but there was no return communication by complainant to provide any supporting details regarding the allegations made. The allegations are deemed unstubstatiated.

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 with administrator about the process and how the facility will receive a copy of this report and the e-signing of this document. A copy of this report is sent to the licensee via email and mailed hardcopy.

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: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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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