415601127-2-7-2024-14-AS-KHOS-D32RDV-20240304115634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 02/07/2024
Date Signed: 02/07/2024 02:53:50 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
12/07/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231207160004

FACILITY NAME:	SERRA HIGHLANDS SENIOR LIVING		FACILITY NUMBER:	415601127
ADMINISTRATOR:	SHAYAN GHEISAR		FACILITY TYPE:	740
ADDRESS:	501 KING DRIVE		TELEPHONE:	(650) 878-5111
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	120	CENSUS: 59	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Administrator Shayan Sheisar		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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- Staff does not ensure residents are spoken to in an appropriate manner
- Staff do not ensure residents are served food of good quality and quantity
- Staff do not ensure a clean safe environment is provided for residents in care

INVESTIGATION FINDINGS:

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On 02/07/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver fidingings in regards to the allegations received. LPA met with Shayan Gheishar and explained the purpose of today's visit.

During the investigation LPA made observations and conudcted interviews. LPA observed the areas under construction dnd did not observe any power tools or supplies in the hallways or walkways of the facility. The facility is renovating some rooms on the second floor. Those rooms are observed to have the doors closed. There was no dust in the hall or walkways the rooms are attached to. The facility kept the doors closed to prevent dust from exiting the rooms. LPA did not smell or observe any toxic items being used during the renovation process and was told that the items being used are legal and approved for such building projects. LPA did not observe any construction dust in the hallway outside of those rooms. No dust was observed on shoes or rails. The city's building and permitting department inspected the construction and found no anomolies and provided suggestions on how to add additional measures to help.

Continued on next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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-20231207160004

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: SERRA HIGHLANDS SENIOR LIVING	FACILITY NUMBER: 415601127
	VISIT DATE: 02/07/2024

NARRATIVE

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Page 2 - LIC9099

Food services and meals are served per menus and suggested serving sizes and USDA recommendations. Residents with modified diets, prescribed diets, or adjusted diets due to health conditions are provided those meals based on those needs. Additionally if residents do want more food they are allowed to request additional servings depending on availability. Interviews conducted cannot provide evidence to show that residents are being spoken to in inappropriate ways. Communications may have been perceived as being dismissive, or being spoken to inappropriately, but LPA does not have a preponderance of evidence to show that did take place in the manner in which it was described. These allegations are unsubstantiated.

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 Shayan Gheishar.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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