415601077-1-4-2023-14-AS-KHOS-CNDS64-20230124123518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601077
Report Date: 01/04/2023
Date Signed: 01/04/2023 03:21:29 PM

Unfounded

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
12/28/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221228162629

FACILITY NAME:	CRISTINA'S CARE HOME		FACILITY NUMBER:	415601077
ADMINISTRATOR:	MADRIGAL, OSCAR		FACILITY TYPE:	740
ADDRESS:	1580 CRESTWOOD DRIVE		TELEPHONE:	(650) 737-0803
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	01/04/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator, Oscar Madrigal		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not notify residents authorized representative of residents death

INVESTIGATION FINDINGS:

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On 1/4/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint inspection. LPA met with caregiver, Benito Maglalang and explained the purpose of today's visit. Caregiver contacted the administrator, Oscar Madrigal who arrived at the facility and assisted with the rest of the investigation. LPA Han reviewed the allegation with the administrator.

Regarding to allegation of- staff did not notify resident's authorized representative of resident's death- the reporting party reported that resident #1 (R1)'s family was informed by the facility of R1's passing.

The administrator denied the allegation and stated R1's authorized representative was not a family member, it was the Power of Attorney (POA) who was listed in R1's Advanced Health Care Directive. Therefore, the facility reported R1's passing to R1's POA and not the family member.

Based on R1's Advanced Health Care Directive, LPA validated that the above POA was appointed by R1.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

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-20221228162629

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: CRISTINA'S CARE HOME	FACILITY NUMBER: 415601077
	VISIT DATE: 01/04/2023

NARRATIVE

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LPA interviewed R1's POA who acknowledged that the facility has communicated when R1 passed away and the facility has provided R1's health updates prior to R1's passing.

After the investigation, this allegation is deemed to be unfounded as the facility reported R1's passing to R1's authorized representative who was assigned by R1 as evidenced by R1's Advanced Health Care Directive.

Based on interview, record review and observation, this complaint allegation is determined to be unfounded, meaning that the allegation could not have happened and/or is without a reasonable basis as the facility.

This report is reviewed and discussed with the administrator.

A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2023

LIC9099 (FAS) - (06/04)

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