415601070-8-31-2023-14-AS-KHOS-CVKHV4-20230911063118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 08/31/2023
Date Signed: 08/31/2023 12:25:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
08/22/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230822094152

FACILITY NAME:	PENINSULA DEL REY		FACILITY NUMBER:	415601070
ADMINISTRATOR:	TAZAWA, KATHERINE		FACILITY TYPE:	740
ADDRESS:	165 PIERCE STREET		TELEPHONE:	(650) 992-2100
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	150	CENSUS: 105	DATE:	08/31/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Katherine Tazawa		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Facility staff do not answer resident's call button in a timely manner.

INVESTIGATION FINDINGS:

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On August 31, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Katherine Tazawa and explained the purpose of the visit.

Regarding the allegation facility staff do not answer resident's call button in a timely manner, according to the reporting party, on 8/20/2023 at around 9:15am, Resident 1 (R1) accidentally touched the service alarm button and the facility staff failed to turn off the service call alarm.

During the investigation, LPA interviewed the Administrator, Assisted Living Director, Maria Alcantra, and Business Office Manager, Jed Nallas and they all denied this allegation and indicated that the facility's protocol is, when a service call alarm turns on, the front desk calls the resident's apartment to check to see what the resident needs. According to Administrator, Assisted Living Director and Business Office Manager, it was indicated that when the service call alarm turned on for R1 on 8/20/2023, the front desk receptionist called R1's room around 9:30am and R1 indicated that he/she was okay. According to interviewed staff, they indicated the med-tech on duty went to R1's room around 11am to turn off the service call alarm. (CONT. TO 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

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-20230822094152

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PENINSULA DEL REY	FACILITY NUMBER: 415601070
	VISIT DATE: 08/31/2023

NARRATIVE

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During the investigation, LPA also interviewed the front desk receptionist that called R1's room and the Med-Tech that went to turn off the service call alarm. According to the front desk receptionist on duty on 8/20/2023, he indicated that when he called R1's room, R1 indicated that he/she was okay and did not need assistance. In addition, according to the Med-Tech interviewed on duty on 8/20/2023, she indicated that she went to R1's room around 11am to turn off the service call alarm.

Furthermore, according to the administrator, in March of 2023, R1's responsible party sent an email to the administrator and the assisted living director, stating that no one is allowed to go into R1's room without prior approval or permission from R1's responsible party.

Therefore, based on the interviews conducted and information collected, the allegation facility staff do not answer resident's call button in a timely manner is deemed to be unsubstantiated meaning although these allegation 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 allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2023

LIC9099 (FAS) - (06/04)

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