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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 03/27/2024
Date Signed: 03/27/2024 11:47:33 AM

Unsubstantiated


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
01/08/2024 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240108140600
FACILITY NAME:SERRA HIGHLANDS SENIOR LIVINGFACILITY NUMBER:
415601127
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:501 KING DRIVETELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 60DATE:
03/27/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Mahogany (Natice) Coles and Jonamar PascuaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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- Licensee not ensuring that infection control practices are maintained

- Facility is malodorous
INVESTIGATION FINDINGS:
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LPA Jeung met with business office director and resident services director (RSD) and reviewed Infection Control Plan and related staff training. Administrator participated by phone.

Based on this investigation--which included observations of supplies of PPE and plastic garbage bags and interviews with staff--these allegations are determined to be unsubstantiated.
Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.
It cannot be determined that caregivers wear the same gloves when caring for more than one resident, nor that shortage of plastic garbage can liners resulted in offensive odors due to absence of trash can liners.

During review and discussion of Infection Control Plan (LIC9282), it is noted that the current Infection Control Preventionist is RSD. Administrator agreed to submit revised ICP and proof of infection control training from a medical professional for RSD. LPA also recommended that documentation of 40 hour new hire training include infection control, as per CCR 87470 Infection Control Requirements.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 03/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
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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