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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600230
Report Date: 07/18/2022
Date Signed: 07/18/2022 11:47:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/11/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220711133013
FACILITY NAME:MARINER'S GREEN RESIDENTIAL CAREFACILITY NUMBER:
415600230
ADMINISTRATOR:GUEVARRA, ANALIZA B.FACILITY TYPE:
740
ADDRESS:380 ENSIGN LANETELEPHONE:
(650) 591-6115
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:6CENSUS: 6DATE:
07/18/2022
UNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Caregiver, Mely GarlandTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff administering supplements to resident without the permission of the resident's authorization representative
INVESTIGATION FINDINGS:
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On July 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Caregiver, Mely Garland and explained the purpose of the visit.

Regarding the allegation that staff are administering supplements to resident without the permission of the resident's authorized representative, according to the complainant, it was indicated that the facility serves a "cloudy" like liquid to residents and is unsure if the facility got authorization from residents family members. During the investigation, LPA interviewed staff and the administrator and it was indicated that the facility gives residents a liquid drink to take as a supplement to boost their immune system. According to the Administrator, he got verbal consent from 5 of the resident's responsible parties to administer the liquid drink to residents, however the Administrator admitted to not asking or receiving consent from a resident's (R1's) responsible party prior to administering the liquid drink.

Based on the information collected and interviews conducted. It was determined that staff are administering supplements to resident without the permission of the resident's authorization representative. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with Caregiver, Mely Garland and a copy is provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/11/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220711133013

FACILITY NAME:MARINER'S GREEN RESIDENTIAL CAREFACILITY NUMBER:
415600230
ADMINISTRATOR:GUEVARRA, ANALIZA B.FACILITY TYPE:
740
ADDRESS:380 ENSIGN LANETELEPHONE:
(650) 591-6115
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94065
CAPACITY:6CENSUS: 6DATE:
07/18/2022
UNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Caregiver, Mely GarlandTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff are not wearing masks.
INVESTIGATION FINDINGS:
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On July 18, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Caregiver, Mely Garland and explained the purpose of the visit.

Regarding the allegation that staff are not wearing masks, according to the complainant, there was a staff member (S1) who was not wearing a mask. In addition, according to the complainant, S1 indicated that he/she was returning back from lunch and will be putting a mask back on. Based on the interviews conducted, S1 removed his/her mask because he/she was on break. In addition, interviewed staff also indicated that there was no residents or staff in close proximity to S1. During the investigation, LPA visited the facility on July 12, 2022 and July 18, 2022 and observed all staff members present at the facility with a face mask.

Therefore, based on observations, the allegation that staff are not wearing masks, 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 reviewed with Caregiver, Mely Garland and a copy is provided with appeals rights.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
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 3
Control Number 14-AS-20220711133013
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MARINER'S GREEN RESIDENTIAL CARE
FACILITY NUMBER: 415600230
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/25/2022
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities:
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.

Violation of this regulation is not met as evidenced by:
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Facility will request both written and verbal consent from resident's responsible party to all facility to administer the liquid drink to resident and put it in resident's files.
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Based on the interviews conducted, the Administrator admitted to not asking or receiving consent from a resident's (R1's) responsible party prior to administering a liquid drink to take as a supplement.

consent from R1's responsible party which poses a potential health and safety risks to residents in care.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 07/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3