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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 10/20/2023
Date Signed: 10/20/2023 11:33:30 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
02/27/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230227091514
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:
10/20/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Katherine TazawaTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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- Staff financially abused resident in care
- Staff did not adhere to the Admission's Agreement
- Staff do not ensure that resident's toileting needs are met
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with Katherine Tazawa and explained the purpose of today's visit.

During the course of the investigation documents were reviewed and interviews were conducted. Due to no further information being received LPA cannot determine if the allegations can be upheld. These allegations are unsubstantatiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with Katherine Tazawa. Copy is provided. No citations are issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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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