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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 419210057
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:59:26 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
02/15/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230215144137
FACILITY NAME:DALE'S HOMEFACILITY NUMBER:
419210057
ADMINISTRATOR:MARISA HOGANFACILITY TYPE:
735
ADDRESS:227 ST. FRANCIS STREETTELEPHONE:
(650) 216-6068
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:4CENSUS: 3DATE:
10/13/2023
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Czarina NavarroTIME COMPLETED:
04:05 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Client in care sustained an unexplained injury
- Staff did not inform client's authorized representative of client's incident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this date Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the allegations received. LPA met with administrator Czarina Navarro and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews and reviewed the records of C1. It is discovered that prior to admission to the facility C1 sustained injuries at a previous facility requiring surgery. Due to C1 cognitive levels and non-verbal status the was staff was unaware of anything specific that may have led them to believe an injury may have been sustained. Facility did send C1 to the hospital at least three times for evaluation and determinations at the hospital did not indicate any injuries that may have led to C1 favoring a wheel chair. There was no injury to report to the responsible party. This allegation is unsubstantiated.

Therefore, based on the interviews conducted and information collected, the allegation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reveiwed with adminstrator Czarina. No citations issued.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2023
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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