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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601059
Report Date: 02/27/2024
Date Signed: 05/02/2024 06:55:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
02/23/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240223141715
FACILITY NAME:PECH5 MG OC LLCFACILITY NUMBER:
415601059
ADMINISTRATOR:VERMA, NEERUFACILITY TYPE:
740
ADDRESS:800 ROBLE AVENUETELEPHONE:
(408) 807-1984
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY:45CENSUS: 23DATE:
02/27/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Neeru VermaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Uncleared adults are allowed to work at the facility
INVESTIGATION FINDINGS:
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On 2/27/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator,Neeru Verma and explained the purpose of the visit.

Regarding the allegation of uncleared adults are allowed to work at the facility, the reporting party (RP) stated that Administrator has allowed two individuals to work while their criminal record clearance are pending in Guardian.

Upon arriving at the facility, LPA Donato observed one of the individuals (S1) in the activity room with the residents. S1 was asked to leave the facility.

While doing records review, LPA observed another individual (S2) who provided staff training on 2/2/24 while status is also pending in Guardian. LPA advised the Administrator that since status is still pending in Guardian, both S1 & S2 are not allowed to work in the facility.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. A civil penalty is being assessed for the amount of $500 ($100 per day x 5 days = $500), for S1 and $100 ($100 per day x 1 day = $100), for S2 for working at the facility without fingerprint clearance. Please see LIC 421BG.

This report was reviewed with and a copy of the report and appeal rights was provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2024
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-20240223141715
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PECH5 MG OC LLC
FACILITY NUMBER: 415601059
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2024
Section Cited
CCR
87355(e)(1)
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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or ... This requirement was not met as evidenced by:
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Staff (S1) was immediately dismissed from work and will not return until a fingerprint clearance has been obtained, S2 only worked one day for training. Licensee will send a written plan to ensure all staff are fingerprint cleared and associated to the facility by POC due date.
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Based on record review, interview, and observation the Licensee did not comply with the section cited above for S1 & S2 working in the facility without fingerprint clearance which poses an immediate health, safety, and personal rights risk to persons in care.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2024
LIC9099 (FAS) - (06/04)
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