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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601122
Report Date: 03/09/2022
Date Signed: 03/16/2022 08:11:20 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
02/22/2022 and conducted by Evaluator Komal Charitra
COMPLAINT CONTROL NUMBER: 14-AS-20220222094818
FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:4CENSUS: 3DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Adminstrator, Victoria AlejandroTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility bathroom is in disrepair
Staff is sleeping in the garage
INVESTIGATION FINDINGS:
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On March 15, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA was greeted by Administrator, Victoria Alejandro and explained the purpose of the visit.

Regarding the allegation that facility bathroom is in disrepair, according to the complainant, the bathroom faucet was broken, and the bathroom shower and toilet were clogged. On February 25, 2022, LPA Charitra conducted the unannounced 10-day complaint visit and observed the three bathrooms in the facility. LPA observed that the faucet was broken in the male’s bathroom. According to the staff, it was indicated that the toilet in one of the bathrooms require multiple flushes if there is a lot of bowel or toilet paper in the toilet. LPA was notified that maintenance was going to come to the facility to fix the toilet.

Based on the observations and information collected, it was determined that the facility was in disrepair.

Based on this information this allegation is substantiated. (CONTINUE TO 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/09/2022
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 4
Control Number 14-AS-20220222094818
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: ARBOR HOUSE
FACILITY NUMBER: 415601122
VISIT DATE: 03/09/2022
NARRATIVE
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Regarding the allegation that staff is sleeping in the garage, according to the complainant, there is a staff member who sleeps in the garage. During the investigation, LPA interviewed four staff members and it was acknowledged that Staff (S1) does sleep in the garage overnight because he/she does not have a place to live. Additionally, S1 admitted to sleeping in the garage on the couch that converts into a bed and keeps personal belongings in his/her car.

Based on the interviews and the information collected, it was determined that S1 has been sleeping in the garage since he/she started working at the facility.

Based on this information this allegation is substantiated.

California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Report is reviewed with Administrator, Victoria Alejandro and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
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
02/22/2022 and conducted by Evaluator Komal Charitra
COMPLAINT CONTROL NUMBER: 14-AS-20220222094818

FACILITY NAME:ARBOR HOUSEFACILITY NUMBER:
415601122
ADMINISTRATOR:ALEJANDRO, VICTORIAFACILITY TYPE:
740
ADDRESS:330 ARBOR DRIVETELEPHONE:
(510) 825-2287
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:4CENSUS: 3DATE:
03/09/2022
UNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Adminstrator, Victoria AlejandroTIME COMPLETED:
04:15 PM
ALLEGATION(S):
1
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3
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9
Staff is smoking inside the facility
INVESTIGATION FINDINGS:
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On March 15, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA was greeted by Administrator, Victoria Alejandro and explained the purpose of the visit.

Regarding the allegation that staff is smoking inside the facility, according to the complainant, staff smokes inside the facility and it smells coming into the facility. On February 25, 2022, when LPA Charitra conducted the unannounced 10-day complaint investigation, LPA toured the garage and inside the facility. LPA did not smell any smoke during the visit. During the investigation, LPA interviewed staff and it was acknowledged that S1 is the only person at the facility who smokes. Interviews indicated that S1 is aware and goes outside in the backyard to smoke.

Based on the interviews and information collected, the allegation that staff is smoking inside the facility is unsubstantiated.
 
Report is reviewed with Administrator, Victoria Alejandro and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
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 4
Control Number 14-AS-20220222094818
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: ARBOR HOUSE
FACILITY NUMBER: 415601122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/22/2022
Section Cited
CCR
87303(a)
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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of
maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Licensee/administrator to fix the bathroom faucet and toilet in the bathroom and provide LPA with a photo indicating that both have been fixed.
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Violation of this regulation is evidence by LPA’s observations noted in LIC9099 and the interviews indicating that the
facility faucet in the men’s bathroom was broken and that the toilet in the resident bathroom required multiple flushes if there is a lot of toilet paper or bowel in the toilet.
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Type B
03/22/2022
Section Cited
CCR
87307(a)(2)
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Personal Accommodation and Services: Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to
provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply… Resident bedrooms shall be provided which meet, at a minimum, the following requirements… No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building…
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Administrator/Licensee to provide LPA acknowledgment of Title 22 Regulations for Personal Accommodation. Administrator/Licensee to submit a new facility floor plan to request for a new fire clearance.
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Violation of this regulation is evidence by all staff interviewed acknowledged that S1 sleeps in the garage.
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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: 03/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4