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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601059
Report Date: 07/29/2021
Date Signed: 07/29/2021 01:11:30 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
07/12/2021 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210712114650
FACILITY NAME:MEADOW GARDENS OF MENLO PARKFACILITY NUMBER:
415601059
ADMINISTRATOR:DESAI, HITEXABEN P.FACILITY TYPE:
740
ADDRESS:800 ROBLE AVENUETELEPHONE:
(650) 322-4100
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:45CENSUS: 9DATE:
07/29/2021
UNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Nancy KlineTIME COMPLETED:
01:15 PM
ALLEGATION(S):
1
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9
Facility did not release past resident's records to resident's authorized representative.
INVESTIGATION FINDINGS:
1
2
3
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5
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9
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12
13
On 07/29/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up on-site complaint inspection visit with Director of Wellness Nancy Kline. LPA explained the purpose of the visit and then delivered the findings.

Concerning the allegation of the facility not releasing a former resident's records, LPA interviewed the Administrator and the complainant. The Administrator, in an interview with the LPA, described the process to prepare the requested documents, as well as completion of a form authorizing the records to be released. LPA Filouane confirmed with the complainant that the facility had delivered the requested documents.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with the Director of Wellness. A copy of the report was emailed to Arturo Lock, Buisness Office Manager.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021
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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