435200308-12-6-2023-26-AS-KHOS-CYEPAQ-20231211100906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435200308
Report Date: 12/05/2023
Date Signed: 12/06/2023 08:04:58 AM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2020 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 26-AS-20200901105518

FACILITY NAME:	MONTE-FARLEY MANOR GUEST HOME		FACILITY NUMBER:	435200308
ADMINISTRATOR:	CARDONA, ELVIRA B.		FACILITY TYPE:	740
ADDRESS:	579 FARLEY STREET		TELEPHONE:	(650) 967-1758
CITY:	MT. VIEW	STATE: CA	ZIP CODE:	94043
CAPACITY:	6	CENSUS: 4	DATE:	12/05/2023
		UNANNOUNCED	TIME BEGAN:	03:16 PM
MET WITH:	Elvira Cardona		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Illegal eviction.

INVESTIGATION FINDINGS:

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On 12/5/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Licensee Elvira Cardona and explained the purpose of today's visit.

Regarding the allegation of illegal eviction, Reporting party (RP) stated that on 8/31/2020 Licensee agreed to take resident back, fully aware of R1s abilities/diagnosis. Upon arrival at the facility, the licensee refused to accept resident stating that they "could not handle the level of care" required for resident because R1 is non-ambulatory.

R1 is diagnosed with schizophrenia and depression and was admitted to facility on 8/12/2020. R1 needs monitoring for medication administration due to resident not swallowing them. Upon admission to facility, R1 has been refusing to eat and take medications and has been constantly screaming every night. R1 was sent back to the hospital on 8/14/23 due to these issues. R1 wasn’t personally assessed by Licensee/Administrator due to COVID-19 pandemic around this time.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

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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Control Number 26-AS-20200901105518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA

FACILITY NAME: MONTE-FARLEY MANOR GUEST HOME	FACILITY NUMBER: 435200308
	VISIT DATE: 12/05/2023

NARRATIVE

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Based on records review, a hospital social worker (SW1) noted that Licensee is considering accepting R1 back if R1’s mood/behaviors stabilize and is willing to take medications consistently on a daily basis. There were also several discussions stating that there should be several options for discharge such as home with 24 hour care vs assisted living/memory care vs back to the current board and care facility with part time care giver. R1 was transported back to the facility on 8/31/2020.

There were also messages exchanged with the payee (P1) and Licensee regarding how the Licensee is not able to contact F1. These exchanges were prior to the discharge date of the resident. Licensee also advised P1 that in order for R1 to be readmitted, F1 should sign the admission agreement otherwise facility is not able to take R1 back.

Based on interview with P1, it was mentioned that R1 was sent to the facility to be discharged from the hospital. P1 also mentioned that the fit wasn’t right. It’s P1s understanding that the hospital misled the Licensee as to what the care would entail. R1 was not taking her medications on a regular basis too, which creates behavioral issues. On the day of the discharge, 8/31/2020, Licensee wasn’t aware that R1 is being discharged that day. Licensee wasn’t able to assess resident prior to discharge. During this time also, Licensee was in contact with R1s responsible party, and the person stated to her to just have R1 return back to the hospital and they will figure out a place that will fit R1s needs.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation mentioned is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed and a copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: 714-293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023

LIC9099 (FAS) - (06/04)

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