415601039-9-22-2022-14-AS-KHOS-CQCP8R-20230328110557

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601039
Report Date: 09/22/2022
Date Signed: 09/22/2022 05:13:05 PM

Unsubstantiated

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
06/02/2022 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220602131917

FACILITY NAME:	CADENCE MILLBRAE		FACILITY NUMBER:	415601039
ADMINISTRATOR:	STROMGREN, KIEL		FACILITY TYPE:	740
ADDRESS:	1201 BROADWAY		TELEPHONE:	(650) 742-9150
CITY:	MILLBRAE	STATE: CA	ZIP CODE:	94030
CAPACITY:	165	CENSUS: 126	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Margaret Madrid and Kacie Wong		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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- Resident’s needs are not being met while in care

- Staff did not ensure that resident is being fed

- Resident’s room is unkempt

INVESTIGATION FINDINGS:

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LPA Jeung observed room where client #1 resides, interviewed client, and discussed current service plan with business office manager and resident services director.

Based upon review of client's file, observation of client's room, interviews with client, staff, and witnesses, this allegation is determined to be unsubstantiated.
In November 2021, client #1 was assessed by facility as independent. Staff were not providing any assistance with ADLs. When client had COVID infection in June 2022, client was unable to care for herself and needed assistance from staff, which was provided, per resident services director. Staff also assisted client with showers, even though this was not stated in client's unsigned service plan. Client had poor appetite and food that staff delivered was not eaten.

Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

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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