415601049-4-26-2023-14-AS-KHOS-CRFKEX-20230502075105

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601049
Report Date: 04/21/2023
Date Signed: 04/26/2023 11:59:04 AM

Substantiated

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
01/06/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230106153247

FACILITY NAME:	HEIRLOOM ROSE GARDEN		FACILITY NUMBER:	415601049
ADMINISTRATOR:	SUNPAYCO, EDMUND		FACILITY TYPE:	740
ADDRESS:	2305 TIPPERARY AVE		TELEPHONE:	(707) 315-9728
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS: 4	DATE:	04/21/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver, Mikhail Serrano		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee will not allow resident to return to the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On April 26, 2023, Licensing Program Analyst (LPA) Komal Charitra made an unannounced visit to deliver an amended report that was provided on April 21, 2023 by LPA Komal Charitra and LPA Grace Donato. LPA met with Caregivers, Mikhail Serrano and explained the purpose of the visit.

On April 21, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Caregivers, Mikhail Serrano and Angelo Sunpayco and explained the purpose of the visit. Administrator, Edmund Sunpayco and Co-Administrator, Rose Lo joined shortly thereafter.

Regarding allegation that Licensee will not allow resident to return to the facility, according to the reporting party, the Co-Administrator was not allowing Resident 1 (R1) to return back to the facility due to R1’s behavior, lack of staffing, and R1’s difficult family dynamic. During the investigation, LPA interviewed Administrator, Co-Administrator, and staff members, reviewed R1’s file and reviewed the hospital discharge documentation.

Based on hospital discharge notes reviewed, R1 was admitted to the hospital on December 9, 2022 due to shortness of breath. On December 28, 2022, R1 was to be discharged back to the facility, however R1 tested for COVID at the hospital. R1 isolated at the hospital till 1/6/2023 and was going to be discharged from the hospital on 1/7/2023, however on 1/6/2023, when the hospital contacted the facility, the Co-administrator indicated that she cannot accept R1 back on 1/6/2023 and 1/7/2023 due to lack of caregivers and having other COVID positive residents at the facility.

Continue to 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 14-AS-20230106153247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM ROSE GARDEN	FACILITY NUMBER: 415601049
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/28/2023 Section Cited CCR 87468.2(a)(20)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents.... Violation of this regulation is evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to review CCR 87468.2(a)(20) and submit acknowledgement of regulation. Administrator/Licensee to submit a written plan of to ensure incident does not happen in the future.
	8 9 10 11 12 13 14	Based on interviews conducted and information collected, the Co-administrator acknowledged, she wanted to have R1 remain at the hospital because the facility was experiencing staffing challenges and was unable to provide for R1 and the other residents at the home until 1/7/2023.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20230106153247

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM ROSE GARDEN	FACILITY NUMBER: 415601049
	VISIT DATE: 04/21/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

According to the Administrator, R1 was to be discharged from the hospital on 1/6/23, but the Co-administrator wanted R1 to remain at the hospital because there were 2 clients that were COVID positive at the facility. In addition, the Co-administrator acknowledged, she wanted to have R1 remain at the hospital because the facility was experiencing staffing challenges and was unable to provide for R1 and the other residents at the home until 1/7/2023. Nevertheless, although R1 returned back to the facility on 1/9/2023, the facility did not want to accept R1 back due to staffing challenges.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Co-Administrator and a copy is provided with appeals rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3