415601048-2-4-2022-14-AS-KHOS-CQCRGV-20230328130122

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601048
Report Date: 02/04/2022
Date Signed: 02/04/2022 06:34:36 PM

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
01/28/2022 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20220128120323

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:	02/04/2022
		UNANNOUNCED	TIME BEGAN:	05:00 PM
MET WITH:	Oscar Madrigal		TIME COMPLETED:	06:45 PM

ALLEGATION(S):

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- Facility failed to maintain working smoke alarms

- Facility failed to report small fire to CCL as required

INVESTIGATION FINDINGS:

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LPA Jeung met with and interviewed staff--including assistant administrator--and tested 6 smoke detectors; all are operable. LPA was told that battery in smoke detector in bedroom #3 was replaced last week. LPA also learned that on January 27 or January 28, a towel that was left in the oven resulted in smoke filling kitchen and moving into adjacent dining room. The smoke detectors are located on the other side of the house where the bedrooms are, and it's conceivable that they were not activated because smoke was confined to the side of the house where the kitchen and dining room are. Staff who were present on 1/27 or 1/28 said that the sliding door and windows were opened to clear the smoke out.
It was evident during LPA's visit that management had not been informed about the smoke incident, so it was not reported to CCLD as an unusual incident. Management will review reporting requirements with staff.

Based on this information, Ii cannot be proven that these allegations are true. Therefore, allegations are determined to be unsubstantiated, meaning that allegations could have occurred or be true, but there is not sufficient evidence to substantiate.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022

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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