435202623-12-5-2024-26-AS-KHOS-DBTLVK-20241210080539

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202623
Report Date: 12/05/2024
Date Signed: 12/05/2024 03:28:40 PM

Unsubstantiated

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
06/26/2023 and conducted by Evaluator David Marrufo

COMPLAINT CONTROL NUMBER: 26-AS-20230626112634

FACILITY NAME:	SUNRISE ASSISTED LIVING OF PALO ALTO		FACILITY NUMBER:	435202623
ADMINISTRATOR:	GRACE KOMASAKA		FACILITY TYPE:	740
ADDRESS:	2701 EL CAMINO REAL		TELEPHONE:	(703) 273-7500
CITY:	PALO ALTO	STATE: CA	ZIP CODE:	94306
CAPACITY:	97	CENSUS: 67	DATE:	12/05/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Stephanie Brice		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Resident is being financially abused
Facility did not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Marrufo conducted an unannounced complaint investigation visit and met with Stephanie Brice, Administrator.

On 06/26/2023, the Department received a complaint with the above allegation. On 06/30/2023, the Department conducted an initial complaint investigation visit. Throughout the investigation, the Department interviewed residents R1-R2, 2 family members of R1-R2, and 8 staff. LPA Marrufo attempted telephone interviews with 2 other staff but was unable to reach them.

LPA Marrufo also obtained copies of R1 and R2’s resident records, LIC624 Incident Report, Theft and Loss Policy, LIC621 Client/Resident Personal Property and Valuables form, Emergency Contact Information Forms, and Progress Notes

See LIC9099-C for more information. Page 1 of 3.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

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 3

Control Number 26-AS-20230626112634

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: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 12/05/2024

NARRATIVE

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An LIC624 Unusual Incident/Injury Report submitted to the Department on 05/26/2023 reports that on 05/21/2023 R1 reported $400 went missing from R1’s apartment. The report states the facility notified the local police department of the missing money.

R1’s Progress Note on 06/22/2023 states that R1 informed facility staff that R2’s diamond ring had gone missing. R1’s Progress Note on 06/23/2023 states that facility staff made a police report with the local police department and a police officer visited R1 to investigate the missing ring.

During interview, R1 and R2 stated that R1 left $400 of cash in a pouch on a nightstand. R1 stated that R1 later checked the pouch and found the $400 to be missing. R1 stated to have reported the missing money to facility staff. R1 then stated R1’s family member brought a safe deposit box to R1’s room for R1 to store the rest of R1 and R2’s valuables. R1 stated to have waited a week before using the safe deposit box. R1 stated when R1 finally tried to collect R1’s valuables in the safe deposit box, R1 noticed that R2’s ring valued at $50,000 was missing. R1 showed LPA Marrufo the plastic bag that contained the ring box which R1 stated contained the missing ring. R1 opened the ring box for LPA Marrufo and LPA Marrufo observed that the box was empty.

During interviews on 07/06/2023, 2 out of 2 family members of R1 and R2 stated to not know what could have happened to the missing money or ring and have no knowledge of where both items could currently be.
During interviews, 8 out of 8 interviewed staff stated to have not stolen the money or ring from R1 and R2’s apartment. 8 out of 8 interviewed staff stated to have not observed or heard about money or a ring being stolen from R1 and R2’s apartment.

Page 2 of 3.

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 26-AS-20230626112634

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: SUNRISE ASSISTED LIVING OF PALO ALTO	FACILITY NUMBER: 435202623
	VISIT DATE: 12/05/2024

NARRATIVE

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LPA Marrufo obtained copies of R1 and R2’s LIC821 Client/Resident Personal Properties and Valuables forms. Both forms have the word “WAIVED” printed on the first and second pages. Both forms indicate R1 and R2 digitally signed the forms on 01/26/2023.

Based on information from interviews conducted with staff, residents, and resident family members, and records reviewed, although the allegation listed above 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.

No Deficiencies were cited under California Code of Regulations Title 22

This report was reviewed with Administrator Stephanie Brice and a copy of the report was provided.

Page 3 of 3.

END REPORT

SUPERVISORS NAME: Sarah Yip
LICENSING EVALUATOR NAME: David Marrufo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2024

LIC9099 (FAS) - (06/04)

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