415601105-11-8-2023-14-AS-KHOS-CY2M83-20231129082227

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601105
Report Date: 11/08/2023
Date Signed: 11/08/2023 11:12:09 AM

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
11/02/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231102153516

FACILITY NAME:	FAMILY AFFAIR CARE HOME		FACILITY NUMBER:	415601105
ADMINISTRATOR:	LESLIE, HUI C.		FACILITY TYPE:	740
ADDRESS:	3100 COLLEGE DR.		TELEPHONE:	(650) 871-5095
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	10	CENSUS: 8	DATE:	11/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Assistant Administrator, XueFei Huang		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Facility allowed unfingerprinted individual to stay at facility without criminal record clearance

INVESTIGATION FINDINGS:

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On 11/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with caregiver, Michael Morales and explained the purpose of today's visit. The assistant administrator, Xue Fei Huang arrived at the facility shortly thereafter and assisted with the rest of the visit.

Regarding to the allegation of facility allowed unfingerprinted individual to stay at the facility without criminal record clearance, the reporting party received an IHSS (In Home Support Services) application for an individual who is currently residing at the facility as a renter and not a resident and in order for IHSS to process the application, they reached out to CCLD for some guidance because it is uncommon for their applicants to be residing at a licensed facility versus a private residence. After received this inquiring, CCLD initiated this complaint to ensure the facility is in compliance with criminal record clearance.

During today's visit, LPA interviewed facility staff, assistant administrator, administrator via phone, greeted the individual-in- question and toured the facility.

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: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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-20231102153516

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: FAMILY AFFAIR CARE HOME	FACILITY NUMBER: 415601105
	VISIT DATE: 11/08/2023

NARRATIVE

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According to the assistant administrator and the administrator, this individual - in -question (R1) was admitted to the facility in April 2023 from Eden Hospital/Sutter Health as a resident and Sutter Health was paying for his/her stay. However, Sutter Health stopped their payment on July 16, 2023 and R1 and R1's responsible party were not able to pay for the monthly fee, therefore, an agreement was reached that R1 would only be responsible to pay for the room and R1's responsible party would be responsible to provide the Activities Of Daily Living.

Based on the documents provided by the facility, LPA observed facility has obtained adequate documents for R1 as a resident.

After the investigation, this allegation is deemed to be unfounded.

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 was discussed and a copy of this report is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC9099 (FAS) - (06/04)

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