415600085-4-18-2024-14-AS-ACON-D59QNA-20240514121849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600085
Report Date: 04/18/2024
Date Signed: 04/18/2024 09:55:36 AM

Unfounded

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
02/27/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240227131710

FACILITY NAME:	ACACIA MANOR		FACILITY NUMBER:	415600085
ADMINISTRATOR:	TAN, LUZVIMINDA		FACILITY TYPE:	740
ADDRESS:	1510 NEWLANDS AVENUE		TELEPHONE:	(650) 579-1915
CITY:	BURLINGAME	STATE: CA	ZIP CODE:	94010
CAPACITY:	6	CENSUS: 2	DATE:	04/18/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Luzviminda Tan		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility does not have a substitute administrator.
Staff are mishandling resident's medications.
Staff are utilizing garage as living area.
Staff do not meet the physical requirements to care and supervise residents.

INVESTIGATION FINDINGS:

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On April 18, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced visit to deliver the investigation findings. LPA met with the administrator and explained the purpose of today's visit.

Regarding to allegation of facility does not have a substitute administrator, the reporting party stated that the administrator goes on vacation very frequently and there is no one in charge when the administrator is gone.

As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that she does not take vacation very frequently and when she does take a vacation, her designated staff would resume the responsibility of the facility and this staff is also a certified administrator.

Based on documents provided by the administrator, the LIC 308( Designation Of Facility Responsibility) indicated that the above staff has been designated by the administrator and the administrator provided a copy of the appointed staff's administrator certification.

After the investigation, this allegation is deemed to be unfounded.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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 14-AS-20240227131710

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: ACACIA MANOR	FACILITY NUMBER: 415600085
	VISIT DATE: 04/18/2024

NARRATIVE

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Regarding to staff are mishandling resident's medications, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that the administrator seems to pocket the medication of hospice residents who passed away and they are been diverted to another country/somewhere else.

As part of the investigation, LPA interviewed the administrator, reviewed facility's centrally stored medication process and reviewed documents.

According to the administrator, when a resident passes away, the administrator is responsible to dispose the remaining medication by completing the Medication Destruction Record and follow the instructions. Once the form is completed and witnessed by a staff member, the administrator will dispose the medication at the local law enforcement department.

LPA observed a resident who recently passed away and all of the remaining medication matched the centrally stored medication and destruction record and the administrator would be disposing them at the local law enforcement department.

After the investigation, this allegation is deemed to be unfounded.

Regarding to allegation of- staff are utilizing garage as living area, the reporting party stated that someone at the facility shared with him/her that the administrator is sleeping in the garage but did not have any additional information.

As part of the investigation, LPA interviewed the administrator, staff, and conducted a tour of the facility.

The administrator denied the allegation and stated no one lives in the garage as it is being used as a storage room.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20240227131710

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: ACACIA MANOR	FACILITY NUMBER: 415600085
	VISIT DATE: 04/18/2024

NARRATIVE

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LPA interviewed staff #1 (S1) who also stated that no ones lives in the garage.

LPA toured the garage and observed that it's being used as a storage space.

After the investigation, this allegation is deemed to be unfounded.

Regarding to allegation of staff do not meet the physical requirements to care and supervise residents, the reporting party stated that staff did not have proper training to care for residents.

Based on staff training records provided by the administrator, LPA observed staff training was completed.

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 and discussed with administrator, and a copy is provided.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC9099 (FAS) - (06/04)

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