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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601063
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:49:00 PM

Unfounded


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
02/28/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240228093037
FACILITY NAME:MISSION WOODSIDEFACILITY NUMBER:
415601063
ADMINISTRATOR:CONDE, GABRIEL V.FACILITY TYPE:
740
ADDRESS:2028 MARYLAND STREETTELEPHONE:
(650) 554-1000
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: DATE:
03/04/2024
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nurse - Laura PaniaguaTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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9
- Staff are not distributing resident's medication as prescribed
- Staff do not ensure that resident's dietary needs are met
INVESTIGATION FINDINGS:
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On 03/04/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to investigate the allegations received. LPA met with nurse Laura Paniagua and explained the purpose of today's visit.

During this investigation LPA conducted interviews and reveiwed pertinent resident records. It is discoverd that the resident was prescribed morphine and the facility provided as prescribed per physician approval and prescription. Facility medication administration record (MAR) indicate and show that the orders were provided to the facility by prescribing physicians and the MAR reflects the administration. According to interviews and the care plan provided, the resident did not require a feeding tube or other method of feeding. The resident was provided food and water depending on the resident's tolerance level of intake. The facility did feed and hydrate the resident. These allegations are unfounded.

This agency has investigated the complaint alleging, Staff are not distributing resident's medication as prescribed and Staff do not ensure that resident's dietary needs are met. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024
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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