415601054-7-30-2021-14-AS-KHOS-C69MRS-20210826095049

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601054
Report Date: 07/30/2021
Date Signed: 07/30/2021 12:04:25 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
08/23/2020 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200823162954

FACILITY NAME:	OLIVIA'S CARE HOME II		FACILITY NUMBER:	415601054
ADMINISTRATOR:	GUZMAN, OLIVIA DE		FACILITY TYPE:	740
ADDRESS:	48 WEST 39TH AVE		TELEPHONE:	(415) 609-4688
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 6	DATE:	07/30/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Olivia De Guzman		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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- Staff member inappropriately handled resident in care

INVESTIGATION FINDINGS:

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Based on investigation that client's personal rights were violated, LPA Jeung determined that this allegation is unsubstantiated. A video on-line dated 11/3/19 depicts a Filipino man standing behind an elderly man in a wheelchair, combing or cutting the elderly man's hair, and smoothing the hair with his hand. The elderly man's face is not clearly visible. According to administrator, the Filipino man was employed from July 2019 until November 2019. LPA verified that his criminal record clearance was associated to facility. LPA's investigation included interviews with staff and witnesses.

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: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2021

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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