415601048-3-13-2023-14-AS-CSMH-CPZN95-20230317101520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601048
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:33:57 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
01/26/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230126160552

FACILITY NAME:	CAPRA HOUSE CARE HOME		FACILITY NUMBER:	415601048
ADMINISTRATOR:	MADRIGAL, PAULA		FACILITY TYPE:	740
ADDRESS:	779 PARK WAY DRIVE		TELEPHONE:	(650) 745-8032
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS: 6	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	03:20 PM
MET WITH:	Juliet Pacaldo		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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- Resident was injured by staff while in care

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings in regards to the investigation on the allegation received. LPA met with the licensee Juliet Pacaldo and explained the purpose of today's visit.

During the investigation LPA conducted multiple interviews and reviewed pertinent documents. Interviews completed resulted in identifying two incidents, which were logged and reported, where a resident could have been injured. LPA could not prove that the resident was injured by staff intentionally. Both incidents discuss the nature of injuries sustained as being accidental where staff were in place and trying to assist the resident. LPA could not prove or disprove this allegation took place.

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. No citations issued. Report is reveiwed with Juliet.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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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