<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 08/15/2024
Date Signed: 08/15/2024 01:37:41 PM

Unsubstantiated


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
07/24/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240724102302
FACILITY NAME:PENINSULA DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: 102DATE:
08/15/2024
UNANNOUNCEDTIME BEGAN:
11:54 AM
MET WITH:Katherine TazawaTIME COMPLETED:
01:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff displayed inappropriate behavior while in front of residents in care
Staff did not ensure resident received adequate food service
Staff does not ensure residents are accorded dignity in their personal relationships with staff, residents, and other persons.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 8/15/2024 , Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director (ED), Katherine Tazawa and explained the purpose of today's visit.

Regarding the allegations of staff displayed inappropriate behavior while in front of residents in care and Staff did not ensure resident received adequate food service, Reporting party (RP) stated that staff disposed of R1s lunch by aggressively slamming the food into the trash in front of R1 and did not replace the meal with another option resulting in the resident not being provided a meal in the facility.

LPA interviewed R1 and it was mentioned that he/she wanted to exchange the meal that was ordered because earlier in the day he/she has already consumed some eggs, so the egg sandwich was too much.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
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 2
Control Number 14-AS-20240724102302
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: PENINSULA DEL REY
FACILITY NUMBER: 415601070
VISIT DATE: 08/15/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
When R1 asked to exchange the meal, S1 asked why and when the reason was explained S1, threw the food in the trash. R1 was asking beforehand if it can just be served again because it was a waste of food. S1 then explained to R1 that they can’t serve food to another resident if it already left the kitchen due to food safety. R1 said that they offered cheeseburger as replacement and R1 agreed to this.

LPA interviewed 2 staff members. S1 mentioned that the food was thrown out due to them not being able to serve it to a different resident per food safety protocols of the facility. S1 is aware the food is being returned and it just so happens that the trash bin is beside S1, by the kitchen door. S1 stated that they did not say anything demeaning to the R1 but instead asked if they would want to order another meal. Another staff, S2, was tasked to get the order of R1 and when the ticket was done it, the meal was immediately prepared. A third staff member, S3, was the one who served the meal while R1 was waiting on the table. RP was not in the vicinity when the alleged altercation happened.

Based on records review, there is a ticket provided by the facility that says that an order was made for a different meal after R1 returned the other food.

Regarding the allegation of staff does not ensure residents are accorded dignity in their personal relationships with staff, residents, and other persons, RP stated that R1 is treated unfairly by staff for being Chinese and not Filipino.

LPA interviewed R1 and it was stated that he/she is happy at the facility and that there are no issues with the staff. LPA also interviewed five other residents with different nationalities, and all mentioned that there is no issue with regards to staff and they are happy here in the facility. R2 mentioned that the staff here have been wonderful, and the stay here has been good. Another resident, R3, mentioned that staff here are friendly and all are very competent, they are kind and not intrusive.

Based on interviews & records review, the department has determined that although the allegations 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.

Report is reviewed and copy is provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2