415601029-3-24-2021-14-AS-JMOS-BZFVGW-20210325162614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601029
Report Date: 03/24/2021
Date Signed: 03/24/2021 10:30:38 AM

Unsubstantiated

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
09/03/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200903125250

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:	03/24/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gwen Wong		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Resident's responsible party did not receive an admission agreement

INVESTIGATION FINDINGS:

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On March 23, 2020 at 1530 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 interviews and reviewed resident documentation. A signed admission agreement is observed with the signature of the DPOA and licensee signed in July 2020. It is discovered that the resident was admitted with a conditional care plan and assessment period due to COVID. Once the assessment period concluded after four weeks a final care plan was ready for signature by DPOA regarding R1. According to the licensee there were communication issues with the DPOA regarding the signing of the new care plan. This delayed the signing by the DPOA from August 2020 to September 2020 and providing the signed admission agreement to the DPOA. Long term care ombusdman and family met with the licensee in September 2020 to discuss and sign the new care plan and provided another copy ofthe admission agreement on this date. LPA attempted to contact the DPOA and family contacts but there was no return communication to provide any supporting details regarding the allegation. The allegation is deemed unstubstatiated.

Based on these observations, the above allegation 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:

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2021

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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