415601070-5-3-2021-14-AS-KHOS-C2QJW8-20210505072419

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 04/30/2021
Date Signed: 05/03/2021 12:36:07 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
03/29/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210329100935

FACILITY NAME:	PENINSULA DEL REY		FACILITY NUMBER:	415601070
ADMINISTRATOR:	CAGULADA, DILLON		FACILITY TYPE:	740
ADDRESS:	165 PIERCE STREET		TELEPHONE:	(650) 992-2100
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	150	CENSUS: 89	DATE:	04/30/2021
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Scott Bissey		TIME COMPLETED:	11:55 AM

ALLEGATION(S):

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Unqualified staff member checked residents blood sugar levels.
Unqualified staff member gave residents insulin.
Unqualified staff member gave residents medication.

INVESTIGATION FINDINGS:

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On 04/30/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. Because of COVID-19 and social distancing measures, LPA Filouane called and spoke to Facility Director (FD), Scott Bissey, and the Executive Director over the phone and delivered the findings.

Concerning the allegation of one unqualified staff checking the blood sugar levels of residents, LPA Filouane interviewed the Facility Director, interviewed staff members, reviewed staff training records, and reviewed resident medication records. The FD denied this allegation in an interview. In interviews, facility staff members stated that they had not witnessed the alleged unqualified staff member checking the blood sugar levels of residents. Additionally, staff confirmed in interviews that only staff members who are properly trained assist residents with medication. In an interview with the LPA, the staff member in question stated they were properly trained for the hand-over-hand technique by a Licensed Vocational Nurse. LPA Filouane reviewed the staff member in question's training files and observed current training for medication assistance. After review, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

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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Control Number 14-AS-20210329100935

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA DEL REY	FACILITY NUMBER: 415601070
	VISIT DATE: 04/30/2021

NARRATIVE

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Concerning the allegation of one unqualified staff member administering insulin injections for residents, LPA Filouane interviewed the FD, interviewed staff members, reviewed staff training records, and reviewed resident medication records. The FD denied this allegation in an interview. In facility staff interviews, LPA Filouane verified that the staff member in question was using the hand-over-hand technique to assist residents with medication. According to PIN 17-09-ASC of the California Department of Social Services, "licensees and their designated facility staff are limited to "assistance with self-administration" and are prohibited from 'administering' medications." In interviews with facility staff members, staff members stated they had not witnessed the alleged unqualified staff member administering insulin injections to residents. Staff also stated in interviews that only properly trained individuals assist residents with medication and injections using the hand-over-hand technique. LPA Filouane reviewed the staff member in question's training files and observed current training for medication assistance. After review, this allegation is unsubstantiated.

Concerning the allegation of one unqualified staff member giving residents medication, LPA Filouane interviewed the FD, interviewed staff members, reviewed staff training records, and reviewed resident medication records. The FD denied this allegation in an interview. Facility staff members stated in interviews they had not witnessed the alleged unqualified staff member giving residents medication. LPA Filouane reviewed the staff member in question's training files and observed current training for medication assistance. After review, this allegation is unsubstantiated.

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

Exit interview conducted with the Facility Director and Executive Director over the phone. The Facility Director will receive this LIC9099 report through email or mail to sign and then will email or mail the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2021

LIC9099 (FAS) - (06/04)

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