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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 06/16/2023
Date Signed: 06/16/2023 10:51:36 AM

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
04/13/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230413130511
FACILITY NAME:PENINSULA DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:CAGULADA, DILLONFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: 104DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Katherine TawazaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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-Staff withholds food from residents
-Staff does not treat residents with dignity and respect
INVESTIGATION FINDINGS:
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On June 16, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA net with Administrator, Katherine Tazawa and explained the purpose of the visit.

Regarding the allegation that staff withholds food from residents, according to the reporting party, the Business Manager told the Dining Room Manager that Resident 1 (R1) was late on rent and withhold R1’s meals at the facility.

During the investigation, LPA interviewed the administrator and alleged staff. According to the administrator, she has never observed staff withhold food from any residents due to resident being late on rent. In addition, the administrator indicated that both her and the Business Manager do not disclose billing/financial information to any staff or residents and all services are continued to be provided to residents regardless of their billing status. According to the Dining Room Manager, he/she has never withheld food from any residents and serves residents three meals a day based on their dietary needs. In addition, he/she indicated that he/she unaware of resident financial/billing information.

CONT. TO 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
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-20230413130511
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: 06/16/2023
NARRATIVE
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Regarding the allegation staff does not treat residents with dignity and respect, according to the reporting party, the facility management is cruel, lacks sympathy and only cares about protecting their own kind of ethnic race.

During the investigation, LPA interviewed the administrator, staff and residents. The administrator denied this allegation and indicated that staff are welcoming to all residents and any visitors that visit the facility. Based on 2/2 staff interviewed and 4/4 residents interviewed, it was indicated that they have never observed staff being discriminatory or disrespectful. Residents interviewed indicated that staff are welcoming, respectful and attentive to residents and families.

Based on the interviews conducted and information collected, these allegations 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.

Report is reviewed with Administrator and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
04/13/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230413130511

FACILITY NAME:PENINSULA DEL REYFACILITY NUMBER:
415601070
ADMINISTRATOR:CAGULADA, DILLONFACILITY TYPE:
740
ADDRESS:165 PIERCE STREETTELEPHONE:
(650) 992-2100
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:150CENSUS: DATE:
06/16/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Katherine TawazaTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff is retaliating against resident for filing a complaint against facility.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On June 16, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Administrator, Katherine Tawaza and explained the purpose of the visit.

Regarding the allegation that staff is retaliating against resident for filing a complaint against the facility, no further information is forthcoming. However, during the initial contact, the reporting party indicated that the Business Manager and the Dining Room Manager retaliated against Resident 1 (R1) because the Dining Room Manager withheld food from R1.

During the investigation, LPA interviewed the Dining Room Manager and the Business Manager. According to the Business Manager, he/she denied this allegation and indicated that financial/billing information is not disclosed to any staff or residents besides the Administrator, Katherine Tawaza. In addition, he/she stated that staff are welcoming and caring to R1. Furthermore, according to the Dining Room Manager, he/she also denied this allegation and indicated that meals are provided to all residents as required. Dining Room Manager and Administrator indicated that if a resident leaves the facility during meal time, the facility keeps the resident’s food and serves it upon return.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed with Administrator, Katherine Tawaza and a copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3