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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600855
Report Date: 09/19/2024
Date Signed: 09/19/2024 10:37:27 AM

Unsubstantiated


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
08/13/2024 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240813105045
FACILITY NAME:ARAVILLE RESIDENTIAL CARE HOME IIFACILITY NUMBER:
415600855
ADMINISTRATOR:PANIZA, DORIEFACILITY TYPE:
740
ADDRESS:1136 VERMONT AVENUETELEPHONE:
(650) 799-5722
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 4DATE:
09/19/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Mila De VillaTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility staff are not serving food in a safe and healthful manner.
Facility staff are not ensuring that incontinent residents are kept clean and dry.
Facility staff are withholding fluids to control incontinence.
Facility staff are not properly trained resulting in injuries to the resident.
INVESTIGATION FINDINGS:
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On September 19, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to delivery the complaint investigation findings. LPA met with caregiver Mila De Villa and explained the purpose of today's visit.

Regarding to the allegation of - facility staff are not serving food in a safe and healthful manner, the reporting party stated that the food is being served cold.

As part of the investigation, LPA interviewed resident-in-question(R1), other residents and staff.

According to R1 and the other residents, they were not being served cold food. They stated that the food is good and one of the residents stated that sometimes the food was served luke warm but it was never cold and staff would heat it up if they requested for it.

According to staff, the food was not cold and if the residents wanted it warmer, they would heat it up.

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

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
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 4
Control Number 14-AS-20240813105045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855
VISIT DATE: 09/19/2024
NARRATIVE
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Regarding to the allegation of facility staff are not ensuring that incontinent residents are kept cleaned, the reporting party stated that resident #1 (R1) is only being changed 2x/day.

As part of the investigation, LPA conducted observation, interviewed staff, visiting home health licensed professional, and other residents.

During LPA's visit on 8/14/2024, LPA observed R1 who was laying in bed, appeared with bright affect, and cleaned.

According to staff, they changed R1 2-3x/day and as needed. They also stated that they checked on R1 several times a day to make sure R1 was cleaned and dry.

According to the visiting home health licensed professional, R1 was always cleaned and dry during their visits.

The other residents stated that facility staff are cleaning and changing them when needed and sometimes it took a little longer when they were busy.

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

Regarding to the allegation of- facility staff are withholding fluids to control incontinence, the reporting party stated R1 was not being provided with water/fluids and the responsible party has to provided during visits.

As part of the investigation, LPA conducted observation, interviewed R1, other residents and staff.

During LPA's visit on 8/14/2024, LPA observed R1's water bottles were placed in R1's room and other residents have their water bottles next to their beds as well.

According to staff, R1 needed assistance with drinking water so they placed the water bottles in the room and offered it during meals, and through-out the day. The also stated that they would fill-up all the resident's water bottles when needed.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20240813105045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855
VISIT DATE: 09/19/2024
NARRATIVE
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LPA interviewed R1 who stated that staff would ensure that he/she has water through-out the day and the other residents also stated that they always have water next to their beds.

After the investigation, this allegation is unsubstantiated.

Regarding to the allegation of- facility staff are not properly trained resulting in injuries to the resident, the reporting party stated that R1's responsible party noted bruises on R1's fingers and arms.

As part of the investigation, LPA reviewed staff training records, R1's medical records, interviewed staff, administrator, and other residents.

LPA interviewed the administrator who denied the allegation and stated R1 has been at the facility for several years and the responsible party has not reported that staff was not trained resulting bruises on R1's fingers and arms. In addition, the administrator stated that facility staff members are experienced and trained to care for the residents.

LPA interviewed staff member who denied the allegation and stated that they have been caring for R1 for many years and they were familiar with R1's skin condition, medications, daily routines, etc. They stated that R1 is at risk for bruises due to a medication that R1 is taking and has been taking it for many years.

LPA interviewed the visiting home health licensed professional who stated that R1 was prone to bruises/skin discoloration due to age and a medication that R1 was taking. The home health licensed professional also stated that based on his/her observation, facility staff members were competent and trained to care for the residents and they were providing good care.

LPA interviewed other residents and they stated that staff members were professional, caring and knowledgeable of their jobs.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20240813105045
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600855
VISIT DATE: 09/19/2024
NARRATIVE
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Based on the training records provided by the facility, LPA observed facility staff completed their annual training.

Based on R1's Centrally Stored Medication And Destruction Record, LPA observed R1 is taking the medication that was reported by the staff and according to Mayo Clinic, one of the side affects of this medication is bruising or purple areas on the skin.

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

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the caregiver, Mila De Villa.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4