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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601034
Report Date: 02/22/2024
Date Signed: 02/22/2024 09:56:05 AM

Unfounded


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
02/06/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240206093051
FACILITY NAME:PENINSULA ELDERLY CARE HOME-LAUREL LLCFACILITY NUMBER:
415601034
ADMINISTRATOR:TOBIAS, JENNIFERFACILITY TYPE:
740
ADDRESS:1064 LAUREL STREETTELEPHONE:
(650) 264-8350
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:12CENSUS: 7DATE:
02/22/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Jennifer TobiasTIME COMPLETED:
10:05 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Staff interfered with authorized representative’s medical decision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On February 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Administrator, Jennifer Tobias and explained the purpose of the visit.

Regarding the allegation, staff interfered with authorized representative’s medical decision, according to the reporting party, Resident 1’s (R1’s) authorized representative wanted to continue R1’s care with HealthFlex Hospice as they are familiar with R1’s needs, however the administrator told R1’s authorized representative that the facility will be requesting a transfer to a different hospice agency. In addition, the reporting party indicated that R1’s authorized representative was distraught about being coerced in using the facility’s preferred hospice agency.

During the investigation, LPA conducted interviews, and reviewed R1’s file. Administrator and Licensee denied this allegation and indicated that they have never forced any resident or family member to choose a hospice agency. According to the Administrator, R1 is currently not on hospice. Administrator indicated that R1 was with HealthFlex Home Health and was in the process of being admitted to HealthFlex hospice, however R1’s authorized representative indicated that he/she requested for another hospice agency to care for R1 but was taken to the hospital. R1 currently is still with HealthFlex Home Health and does not require hospice care. According to R1’s authorized representative interviewed, R1’s physician ordered R1 to be under the care of HealthFlex hospice, however R1’s authorized representative wanted to explore more options and preferred a different hospice agency over the one recommended by the doctor. In addition, R1’s authorized representative denied being forced into choosing a different hospice agency as HealthFlex was not chosen by him/her.

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 is reviewed with administrator, and a copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
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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