415600837-4-9-2021-14-AS-JMOS-C28ND8-20210419102152

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600837
Report Date: 04/09/2021
Date Signed: 04/09/2021 03:11:24 PM

Unsubstantiated

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
08/27/2020 and conducted by Evaluator Christopher Hopkins-Clarke

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200827094643

FACILITY NAME:	COMPLETE SENIOR LIVING, INC		FACILITY NUMBER:	415600837
ADMINISTRATOR:	FRAGIACOMO, VIVIAN		FACILITY TYPE:	740
ADDRESS:	601 N. IDAHO		TELEPHONE:	(650) 579-1234
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	6	CENSUS: 6	DATE:	04/09/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Vivian Fragiacomo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff neglected resident while in care causing injury.
-Staff neglected to give proper wound care.
-Staff falsified documents
-Staff prohibited hospice from entering the facility.
-Staff did not notice a change in resident's condition.
-Staff did not follow resident's hospice care plan.
-Unqualified staff providing wound care service to resident's

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/9/2021 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint investigation regarding the above allegation. LPA met with Administrator Vivian Fragiacomo via tele-visit due to Covid-19 procedures and explained the purpose of the tele-visit.

Regarding the allegations above, LPA Bertha Raygoza conducted the investigations, and based on interviews with Administrator, staff, and resident, it was deemed that the resident was not neglected, resident received proper care/ treatment, there was no falsying of documents, and hospice was allowed in the facility. Although the allegations 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.

An exit interview was conducted. Report was discussed with and emailed to Administrator Vivian Fragiacomo for signature.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Christopher Hopkins-Clarke
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2021

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 1