415601129-8-2-2023-14-AS-CSMH-CUJMLJ-20230809094226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601129
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:11:59 PM

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
07/26/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230726130737

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: 13	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator, Loi Bustamante		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Facility staff are administering Insulin injections

INVESTIGATION FINDINGS:

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On August 2, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint # 14-AS-20230726130737. LPA Han met with the administrator, Loi Bustamante and explained the purpose of the visit.

As part of the investigation, LPA interviewed administrator, facility staff, resident, and reviewed documents.

Regarding to allegation of facility staff are administering insulin injections- there is no additional information forthcoming from the reporting party. LPA interviewed administrator who denied the allegation and stated facility has one resident (R1) who requires insulin injection that is performed by him/herself and facility staff performed handheld assistance when needed.

Unsubstantiated

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: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

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 3

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
07/26/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230726130737

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: 13	DATE:	08/02/2023
		UNANNOUNCED	TIME BEGAN:	09:50 AM
MET WITH:	Administrator, Loi Bustamante		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Uncleared staff are working at the facility

INVESTIGATION FINDINGS:

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On August 2, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint # 14-AS-20230726130737. LPA Han met with the administrator, Loi Bustamante and explained the purpose of the visit.

Regarding to allegation of uncleared staff are working at the facility- there is no additional information forthcoming from the reporting party.

As part of the investigation, LPA interviewed administrator and reviewed facility staff files.

LPA reviewed 8 facility staff personnel files and observed all them staff are cleared to work and associated with the facility.

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 is reviewed with Administrator, Loi Bustamante and a copy is provided.

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: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20230726130737

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: 08/02/2023

NARRATIVE

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LPA interviewed R1 who stated that he/she administered their own insulin on a daily basis before each meal and at bedtime.

LPA interviewed 2 caregivers/medication technicians and both of them stated that R1 administered his/her own insulin injection on a daily basis and they provided handheld assistance when needed. However, both of them also reported that they performed glucose finger stick testing for R1 on a daily basis and this practice was acknowledged by the administrator.

After the investigation, this allegation is deemed to be unsubstantiated. However, facility staff are administering glucose finger stick testing for R1 that should be completed by an appropriately skilled professional. This deficiency will be cited on LIC809 and 809D under case management.

Although the above investigation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the administrator, Loi Bustamante. A copy is provided.

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: 08/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3