415601039-3-5-2021-14-AS-KHOS-BYYK28-20210310063042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601039
Report Date: 03/04/2021
Date Signed: 03/05/2021 01:42:19 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
06/09/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200609142355

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:	188	CENSUS: 100	DATE:	03/04/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Kiel Stromgren, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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- unlawful eviction
- unexplained injuries

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza made an unannounced virtual Televisit with Administrator, Kiel and stated purpose of subsequent visit.

- unexplained injuries. Based on record review of the R1's physician report and medical records. Based on interviews of Injuries being sustained due to fall. Based on Physician report with same previous injuries with same scenarios due to medical condition. Therefore, the allegation was unsbustantiated.
- unexplained evictions. Based on no eviction letter provided to resident. Based on Meeting with family and facility, it was agreed with family to take R1 out of community and a reimbursement check was issued to family. Therefore, the allegation was unsubstantiated.

Although the above 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 allegations are deemed UNSUBSTANTIATED at this time.

This report was reviewed with Administrator, Kiel Stromgren.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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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