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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600837
Report Date: 01/04/2024
Date Signed: 01/04/2024 03:20:23 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
12/05/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231205102303
FACILITY NAME:COMPLETE SENIOR LIVING, INCFACILITY NUMBER:
415600837
ADMINISTRATOR:FRAGIACOMO, VIVIANFACILITY TYPE:
740
ADDRESS:601 N. IDAHOTELEPHONE:
(650) 579-1234
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
01/04/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator - Vivian FragiacomoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Resident was illegally evicted
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/04/2023 at 2:30pm, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver finidings regarding the allegations referenced above. LPA met with administrator Vivian Fragiacomo and explained the purpose of today's visit.

During the course of the investigation, LPA conducted inteviews, and reviewed documents received from the facility pertinent to the investigation and R1. It is found that there is conflicting information recieved from the complainant versus the facility and other interviews conducted. The resident was not evicted as the facility did not evict R1, and rather R1 was voluntairly removed from the facility by the responsible party per items reviewed. This allegation is unfounded.

This agency has investigated the complaint alleging, "Residnet was illegally evicted". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

No citations issued. Report is reviewed with Vivian.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
12/05/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231205102303

FACILITY NAME:COMPLETE SENIOR LIVING, INCFACILITY NUMBER:
415600837
ADMINISTRATOR:FRAGIACOMO, VIVIANFACILITY TYPE:
740
ADDRESS:601 N. IDAHOTELEPHONE:
(650) 579-1234
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
01/04/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator - Vivian FragiacomoTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff did not report incidents to resident's responsible party
- Staff did not administer resident's medication as prescribed
- Staff administered discontinued medication to a resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/04/2023 at 2:30pm, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver finidings regarding the allegations referenced above. LPA met with administrator Vivian Fragiacomo and explained the purpose of today's visit.

During the course of the investigation, LPA conducted inteviews, and reviewed documents received from the facility pertinent to the investigation and R1. It is found that there is conflicting information recieved from the complainant versus the facility and other interviews conducted. Incident reports were viewed and observed as reported to the responsible party. Medications according to administration record reviewed show the medications were given according to prescription directives. There was an issue discovered where there were communication blocks put in place by the responsible party. The PCP was not allowed to communicate with the facility directly so orders were not received and would not respond to the facility's requests for information and directives. These allegations are unsubstatiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

No ciations issued. Report is reviewed with Vivian.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2