415601070-8-15-2024-14-AS-AMEN-D8DLHV-20240822084654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601070
Report Date: 08/15/2024
Date Signed: 08/15/2024 01:36:51 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
07/23/2024 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240723151606

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: 102	DATE:	08/15/2024
		UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	Katherine Tazawa		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff refusing to assist resident with CPAP machine

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (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 3

Control Number 14-AS-20240723151606

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

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During the course of the investigation, LPA interviewed 2 staff members. S2 mentioned that S1 did the assessment. During training with Med Aid and S1, R1 freaked out. The responsible party wants R1 to try again. No show on the scheduled time, rescheduled and nobody was there again. LPA also interviewed R1 and he/she stated that he/she doesn’t want to use the CPAP machine. A police officer (PO) also visited the facility and had the ED accompany them in R1s room, R1 also stated to them that “I don’t want to use the CPAP." S1 was also interviewed and mentioned that he/she did not use that language to R1.

There has been several attempts for R1 to try and be trained with the machine. Several schedules have been made. As of this report, R1 has already agreed to use it and additional staff has been trained to assist R1 with the use of the machine.

Based on records review, S1 visited R1s room on 7/22/24 with another staff member, S3. R1 was scheduled to have another training at 2pm. Staff knocked and no one was in the room. They waited for 10 minutes then advised responsible party that no one was in the room.

Based on interviews & records review, the department has determined that although the allegation 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 Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (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 3

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
07/23/2024 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20240723151606

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: 106	DATE:	08/15/2024
		UNANNOUNCED	TIME BEGAN:	10:42 AM
MET WITH:	Katherine Tazawa		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff unable to effectively communicate with resident due to a language barrier

INVESTIGATION FINDINGS:

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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 allegation of facility staff unable to effectively communicate with resident due to a language barrier, RP stated that there is a language barrier preventing staff from being able to effectively communicate with the R1 and facility has not provided an interpreter when attempting to educate and assist the resident with the CPAP.

LPA interviewed R1 and was communicating using English as the primary language. There was no need for an interpreter as LPA was able to converse with R1. Additionally, LPA interviewed the ED and mentioned that there was no request of an interpreter from R1 or the responsible party. Had there been then it would be provided accordingly.

Based on interviews and observations, the department has determined that that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (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: 3 of 3