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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600358
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:36:21 PM

Substantiated


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
10/27/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231027125651
FACILITY NAME:AHAU BOARDING CARE HOMEFACILITY NUMBER:
415600358
ADMINISTRATOR:LATU, TEMALETI T.FACILITY TYPE:
740
ADDRESS:901 KAINS AVENUETELEPHONE:
(650) 866-9172
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:5CENSUS: 5DATE:
11/01/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Temaleti LatuTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Due to staff negligence, medications were accessible to residents
INVESTIGATION FINDINGS:
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On 11/1/2023, Licensing Program Analyst (LPA) Murial Han conducted a 10-day complaint visit. LPA met with administrator and explained the purpose of today's visit.

Regarding to allegation of- due to staff negligence, medications were accessible to residents, the reporting party report that one cabinet lock was broken and accessible to resident and another cabinet was closed with a lock, however, the key is permanently in the lock.

During the visit, LPA observed the medicine cabinet with two doors, the doors were closed, however, 2 keys were in the lock and both were not lock. In addition, LPA observed resident's medication placed on the counter below the medicine cabinet.

Above observations were acknowledged by the administrator.

In addition, LPA also made other observations during the visit, see LIC 809 and LIC 809 D under case management for the details.

Based on observations, and interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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 2
Control Number 14-AS-20231027125651
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: AHAU BOARDING CARE HOME
FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
CCR
87565(h)(2)
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87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons...
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The administrator/licensee will provide a plan to ensure medicine cabinet is lock and inaccessible to residents at all times and will provide a copy of the plan to CCL by 11/2/2023.
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This requirement is not met as evidenced by LPA observed medicine cabinet was not locked and resident medications left unattended on the counter below the medicine cabinet which poses an immediate health risk 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: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2