415601101-6-9-2023-14-AS-KHOS-CSQHP7-20230612062152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601101
Report Date: 05/19/2023
Date Signed: 06/09/2023 12:47:14 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
02/14/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230214151033

FACILITY NAME:	AEGIS LIVING SAN FRANCISCO		FACILITY NUMBER:	415601101
ADMINISTRATOR:	CECILIA DAUTH		FACILITY TYPE:	740
ADDRESS:	2280 GELLERT BLVD		TELEPHONE:	(650) 242-4154
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	100	CENSUS: 80	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	David Shaw		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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- Facility staff allowed resident's gifted cell phone of choice to be taken away from them

INVESTIGATION FINDINGS:

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*** Amended document to reflect as a public document***

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the above allegation recieved. LPA met with the business office manager David and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews with facility staff, resident POA, other agencies, and the complainant. Pertinent documentation is also reviewed. Pertinent documents were received and reviewed as part of the investigation. Regarding the phone being allowed to be taken away, the assigned POAs of the resident were responsible for the phone being removed. LPA received photgraphic evidence of the phone and a note that was confirmed to be from the POA. Interviews also confirmed this.

Continued on next page

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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 4

Control Number 14-AS-20230214151033

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: AEGIS LIVING SAN FRANCISCO	FACILITY NUMBER: 415601101
	VISIT DATE: 05/19/2023

NARRATIVE

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Page 2 - LIC9099 - Unfounded

Interviews showed that the resident is unable to operate the cell phone on his/her own due to diagnosis. Even though coached the use of the phone was not easy for the resident. It was the POA decision to remove the phone and it back to the sender with a note attached. The facility was abiding by the assigned POA's wishes. LPA could not deem accountability on this allegation as POA involvement and decision was the reason for removal of the cell phone. The preponderance of evidence standard could not be met per LPA determination. This allegation is unfounded.

This agency has investigated the complaint alleging, facility staff allowed resident's gifted cell phone of choice to be taken away from them. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

No citation issued.

Report is reviewed with business office manager David

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
02/14/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230214151033

FACILITY NAME:	AEGIS LIVING SAN FRANCISCO		FACILITY NUMBER:	415601101
ADMINISTRATOR:	CECILIA DAUTH		FACILITY TYPE:	740
ADDRESS:	2280 GELLERT BLVD		TELEPHONE:	(650) 242-4154
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	100	CENSUS: 80	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	David Shaw		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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- Facility staff did not allow resident to have a visitor in their private room
- Facility staff did not allow resident to have visits outside of the facility
- Facility staff did not treat resident with dignity and respect

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the above allegation recieved. LPA met with the business office manager David and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews with facility staff, resident POA, other agencies, and the complainant. Pertinent documentatin was also reviewed. In regards to the facility did not allow resident to have a visitor in their private room, according to inerviews the POA directive that the visitor to not visit the resident in his/her private room alone with the visitor as it was the first visit by the visitor. It was the wish of the POA for the visit to take place outside of the resident's room and in a public area where supervision could be in place for health and safety reasons of the resident. The facilty abided by the directive of the POA.

Continued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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 4

Control Number 14-AS-20230214151033

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: AEGIS LIVING SAN FRANCISCO	FACILITY NUMBER: 415601101
	VISIT DATE: 05/19/2023

NARRATIVE

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LIC9099 - Page 2

In regards to the allegation of, facility staff did not allow resident to have visits outside of the facility. It was again the directive of the POA on file to not allow outside visits with the resident as a heath and safety concern. The facility also saw that this could be a health and safety risk as the resident does have a diagnosis and other physical limitations that would be difficult for a visitor that is not the POA to be able to handle outside of the care setting. As a health and safety risk this directive was being followed by the facility.

In regards to the allegation of, facility staff did not treat resident with dignity and respect. It was discovered based on interviews that the visitor requested to visit at a specific time and day. Facility staff prepared the visit for the resident and the visitor who arrived 25 minutes after the stated time. The resident was in a public space observable by staff to enable supervision of the resident to ensure the health and safety of the resident prior to the arrival of the visitor. Staff were present in the area to ensure this. The resident was not in put in a situation that would infringe on his/her personal rights in being treated with dignity and respect. LPA could not prove or disprove that the resident was not treated with dignity and respect as it is one party's word over another in regards to the situation.

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.

No citation issued.

Report is reviewed with business office manager David

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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