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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 430701864
Report Date: 11/26/2024
Date Signed: 11/26/2024 02:04:25 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20221128161412
FACILITY NAME:LYTTON GARDENS COMMUNITY CAREFACILITY NUMBER:
430701864
ADMINISTRATOR:DORIS LEEFACILITY TYPE:
740
ADDRESS:649 UNIVERSITY AVENUETELEPHONE:
(650) 617-7338
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:55CENSUS: 42DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Anahi MckaneTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff not wearing masks
Resident was threatened with eviction
INVESTIGATION FINDINGS:
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13
On 11/26/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Anahi Mckane and LPA explained the purpose of the visit.

For the allegation of staff not wearing masks, reporting party (RP) stated that on 11/17/2022, staff not wearing mask at front desk of assisted living.

Based on records review, the California Department of Public Health (CDPH) Mask Guidance, dated 9/20/2022 states that in the following healthcare and long-term care indoor settings, masks are required for all individuals regardless of vaccination status. Surgical masks or higher-level respirators (e.g., N95s, KN95s, KF94s) with good fit are highly recommended. This includes Adult and Senior Care Facilities.

page 1 of 2
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
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 4
Control Number 26-AS-20221128161412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LYTTON GARDENS COMMUNITY CARE
FACILITY NUMBER: 430701864
VISIT DATE: 11/26/2024
NARRATIVE
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According to Provider Information Notice (PIN) 22-28-ASC, effective 9/26/2022, it states that If there are differing requirements between the most current CDC, CDPH, CDSS, CDDS, Cal/OSHA, and local health department guidance or health orders, licensees should follow the strictest requirements.

For the allegation of resident was threatened with eviction,

Resident is not part of assisted living but resides in the independent living area. The issue with eviction is not governed by title 22.

Based on interviews & records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.


page 2 of 2
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/28/2022 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 26-AS-20221128161412

FACILITY NAME:LYTTON GARDENS COMMUNITY CAREFACILITY NUMBER:
430701864
ADMINISTRATOR:DORIS LEEFACILITY TYPE:
740
ADDRESS:649 UNIVERSITY AVENUETELEPHONE:
(650) 617-7338
CITY:PALO ALTOSTATE: CAZIP CODE:
94301
CAPACITY:55CENSUS: 42DATE:
11/26/2024
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Anahi MckaneTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was elbowed by another resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/26/2024, LPA Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Anahi Mckane and LPA explained the purpose of the visit.

Regarding the allegation of resident was elbowed by another resident, RP stated that on 11/13/2022, at the bottom of the elevator, a resident (R1) saw someone (U1) with no face mask, R1 turned to try to get out of the elevator, U1 elbowed R1 on the chest, big bruise.

LPA Maruffo was able to interview 4 staff members. S1 stated that R1 said someone kicked him/her in the chest. S1 doesn’t remember exactly the date that it occurred. The incident was emailed. R1 came to the receptionist desk. The first thing R1 said was that S1 was his/her witness that someone kicked him/her. R1 did not say the name of the person. S2 also confirmed with S1 that a resident reported that he/she came down and talked to S1 that he/she was hit and was attacked.

page 1 of 2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 26-AS-20221128161412
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME: LYTTON GARDENS COMMUNITY CARE
FACILITY NUMBER: 430701864
VISIT DATE: 11/26/2024
NARRATIVE
1
2
3
4
5
6
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8
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R1 did not say who attacked him/her. S2 was able to review cameras in the area and stated that nothing happened. R1 just came down to tell S1 that he/she was hit. S2 looked at the camera in the hallways on the fourth floor and nothing happened.

Based on interviews, the department has determined that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

page 2 of 2
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 11/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4