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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601122
Report Date: 03/28/2022
Date Signed: 03/28/2022 09:55:33 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
01/13/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220113114225
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: DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:House Manager, Homer BautistaTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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-COVID positive staff member provided care and supervision to COVID negative residents introducing COVID into facility
-Facility administrator does not spend required minimum amount of hours at facility
-Facility not following program designed
INVESTIGATION FINDINGS:
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On March 28, 2022 at 8:15am, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with House Manager, Homer Bautista, and explained the purpose of the visit.

On January 13, 2021, the Department received a complaint alleging that there was a COVID positive staff (S1) providing care and supervision to COVID negative residents introducing COVID into the facility. According to the complainant, S1 was providing care and supervision to 3 residents. During the investigation, LPA Charitra interviewed staff and it was indicated that S1 was on his/her way to the facility when he/she received postive results. According to the interviewed staff, two staff members who worked NOC shift at the facility abandoned the facility and the residents to avoid coming in contact with S1, therefore the residents did not have a staff member present to provide care and supervision to the resident. The administrator admitted that she allowed S1, who was COVID positive to provide care and supervision to 3 COVID negative residents with full PPE.

Based on the interviews and information collected, it was determined that the there was a COVID positive staff providing care and supervision to COVID negative residents introducing COVID into the facility. The preponderance of evidence standard has been met; therefore, these allegations are Substantiated. (CONT. TO 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
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 6
Control Number 14-AS-20220113114225
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: 03/28/2022
NARRATIVE
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Regarding the allegation that the facility administrator does not spend sufficient amount of time at the facility, according to the complainant, facility administrator comes to the facility sporadically and mainly to deliver groceries, and she divides her time between two facilities; therefore, she is not present at the facility sufficient amount of time required to ensure that the facility operates accordingly. During the investigation, LPA interviewed staff and it was indicated that the administrator is in the facility 2-3x a week or once every two weeks to deliver groceries. Nevertheless, LPA Charitra interviewed the administrator and it was acknowledged that he/she comes to the facility 3x a week for 2-4 hours.

Based on LPAs observations and interviews which were conducted, it was determined that the administrator does not spend a sufficient amount of time at the facility to meet the administrator qualifications and duties. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Regarding the allegation that the facility is not following program design, according to the complainant, the facility program design requires a 1:1 care between caregivers and residents; however, there are only two staff members providing care and supervision to 3 residents. LPA Charitra reviewed the plan of operations and verified that the facility submitted and got approved a program design requiring 1:1 staffing provided during most waking hours and two staff providing awake supervision and care during sleeping hours. On January 21, 2022, when LPA Charitra conducted the 10-day complaint visit at the facility, LPA observed 3 residents and 2 staff members, one of which was shadowing that day. This indicates that the facility failed to follow the stated plan of operations. Interviewed staff indicated that since the facility went through a change of ownership, the facility has not been able to meet 1:1 care. According to the Administrator, the facility is trying to hire more staff and is trying to comply to the 1:1 program design but it’s been difficult due to staffing. Nevertheless, the licensee failed to follow the program design in order to meet the resident’s care and supervision.

Based on the interviews and documentation, it was determined that the licensee failed to follow the program design and to ensure the proper care and supervision for the residents. Furthermore, the licensee failed to address the staffing concern and find alternative solutions to meet the program design. The preponderance of evidence standard has been met; therefore, this allegation is SUBSTANTIATED.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with House Manager, Homer Bautista, and a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/13/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220113114225

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: DATE:
03/28/2022
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:House Manager, Homer BautistaTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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-Facility was over capacity
-Facility administrator provided Licensing with false claims regarding staffing and resident relocation
INVESTIGATION FINDINGS:
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On March 28, 2022 at 8:15am, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver the findings for the above allegations. LPA met with House Manager, Homer Bautista, and explained the purpose of the visit.

Regarding the allegation that the facility was over capacity, according to the complainant, the licensee moved two staff members with three residents from her other facility to Arbor House. During the investigation, LPA interviewed staff and it was indicated that due to a positive staff member assisting 3 residents and the staffing shortage, the staff members from licensee’s other facility, took all three residents to the facility as backup in case the staff member present at Arbor House needed help. According to the administrator and the interviewed staff, the residents from the other facility did not go into Arbor House. It was indicated that the residents from the other home stayed in the facility van with two staff members until another staff arrived at Arbor House.

Therefore, based on the information collected, and interviews, the allegation that the facility was over capacity is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. (CONT. TO 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20220113114225
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: 03/28/2022
NARRATIVE
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Regarding the allegation that the facility administrator provided Licensing with false claims, regarding staffing and resident relocation; On January 12, 2022, LPA Jamie Vado spoke to Administrator regarding the COVID cases at the facility. According to the administrator, the facility at the time did not have any positive residents and there was a sufficient number of staffs to care for the residents. During the exchange, there was a question whether residents had been relocated to accommodate supervision. The Administrator first denied the relocation, and then reported that indeed there had been a relocation. However, during the investigation, staff interviewed, and information collected indicated that the facility has been short on staff but did not relocate the residents at any point.

Therefore, based on the information collected, and interviews, the allegation that the facility administrator provided licensing with false claims regarding staffing and resident relocation is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with House Manager, Homer Bautista, and a copy is provided
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20220113114225
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: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2022
Section Cited
CCR
87405(a)
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87405(a) Administrator Qualifications: ll facilities shall have a qualified and currently certified administrator… The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section…
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Administrator/Licensee shall take refreshment courses and proper training from approved vendors to demonstrate licensee's ability to maintain administrator certificate. Facility Administrator to submit acknowledgement of Title 22 regulation for Administrator Qualifications and Duties.
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Violation of this regulation is evidence by interviewed staff indicating that the current administrator will mainly come to the facility to drop off groceries once every 2 weeks or come to the facility sporadically. In addition, LPA Charitra interviewed the administrator and it was acknowledged that he/she comes to the facility 3x a week for 2-4 hours. Nevertheless, administrator has failed to spend a sufficient number of hours in the facility to give adequate attention to the administration of the facility.
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Type B
04/04/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

Violation of this regulation is not met as evidenced by:
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Administrator/Licensee to submit acknowledgement of Title 22, Regulations for CCR, Personal Rights of Residents in All Facilities 87468, Personal RIghts of Residents in All Facilities
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According to interviewed staff, it was indicated that there was a COVID positive staff (S1) assisting 3 COVID negative residents at the facility. Additionally, S1 exposed the three residents to an infectious disease, COVID-19, by providing care and supervision to residents in care. Nevertheless, the administrator admitted that she allowed S1 to assist the residents which poses a health and safety risk to the 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: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20220113114225
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: 03/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2022
Section Cited
CCR
87208(a)
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Plan of operation: Each facility shall have and maintain a current, written definitive plan of operation... Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval… The plan and related materials shall contain the following…Statement of purposes and program goals…Administrative organization, Staffing plan, qualifications, and duties. Plan for training staff, as required by Section 87411(c).
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Licensee/Administrator to follow the program design or find a solution to meet the program design.
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Violation of this regulation is not met by facility administrator and interviewed staff indicating that the program design requires a 1:1 care between caregivers and residents; however, there are only two staff members providing care and supervision to 3 residents. Additionally, the interviewed staff indicated that the facility has not been meeting the 1:1 care noted in the program design due to the insufficient number of staff at the facility. Nevertheless, the licensee failed to follow the program design and find an alternative solution to meet the program design.
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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: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6