415601129-1-18-2024-14-AS-KHOS-D2DM8A-20240212082248

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601129
Report Date: 01/18/2024
Date Signed: 01/18/2024 10:31:17 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
11/20/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231120125621

FACILITY NAME:	JLA HEALTHCARE SERVICES LLC		FACILITY NUMBER:	415601129
ADMINISTRATOR:	LEONARD, JEROME		FACILITY TYPE:	740
ADDRESS:	1185 ACACIA STREET		TELEPHONE:	(650) 477-2857
CITY:	MONTARA	STATE: CA	ZIP CODE:	94037
CAPACITY:	24	CENSUS: 17	DATE:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Loi Bustamante		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Staff neglected to supervise resident who swallowed their dentures leading to resident's death

INVESTIGATION FINDINGS:

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On January 18, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint investigation findings. LPA met with administrator and explained the purpose of today's visit.

Regarding to the allegation of- staff neglected to supervise resident who swallowed their dentures leading to resident's death, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party reporting that resident #1 (R1) was transferred to the hospital because R1 accidentally swallowed the denture and such accident caused an infection resulted R1's death and the incident was a gross negligence of 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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-20231120125621

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: JLA HEALTHCARE SERVICES LLC	FACILITY NUMBER: 415601129
	VISIT DATE: 01/18/2024

NARRATIVE

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The Department has completed the investigation and based on hospital records and R1's death certificate, R1's death was not questionable and the facility seek for proper medical assistance when R1 had a change in health condition.

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 is reviewed with administrator Loi Bustamante and 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: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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