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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601122
Report Date: 10/20/2022
Date Signed: 10/20/2022 09:18:04 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
06/09/2022 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220609161732
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:3CENSUS: 3DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Caregiver, Arthur GraceTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Facility not following program designed
INVESTIGATION FINDINGS:
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On October 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Caregiver, Arthur Grace and explained the purpose of the visit.

Regarding the allegation that the facility is not following program design, according to the reporting party, there are 3 residents that are required to have a 1 on 1 caregiver for all 3 shifts according to the program design. During the investigation, LPA reviewed the facility program design and interviewed staff. Based on the program design that the facility submitted and got approved, the facility indicated that 1:1 staffing will be provided during most waking hours and two staff providing awake supervision and care during sleeping hours. On 9/8/2022 and 10/20/2022, LPA Charitra conducted complaint visits to the facility in the morning and observed 2 staff members present both times for the 3 residents. In addition, interviewed staff indicated there are normally 2 staff members present during the AM shift, 2 staff present during the PM shift and 2 staff during NOC shift. Although, the Administrator is constantly hiring staff members for the facility to meet resident's needs and progrm designed, the Licensee failed to follow the program design in order to meet the resident’s care and supervision.

Based on the observations and interviews conducted, it was determined facility is not following program designed. The preponderance of evidence standard has been met, therefore the above allegation is determined to be Substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Caregiver, Arthur Grace, and a copy is provided with appeals rights. Caregiver refused to sign.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
06/09/2022 and conducted by Evaluator Komal Charitra
COMPLAINT CONTROL NUMBER: 14-AS-20220609161732

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:3CENSUS: 3DATE:
10/20/2022
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Caregiver, Arthur GraceTIME COMPLETED:
09:25 AM
ALLEGATION(S):
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Resident left in bathroom for an extended period of time
Staff humiliate resident in public setting
Unqualified staff are providing medications to residents without proper training
INVESTIGATION FINDINGS:
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On October 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegation. LPA met with Caregiver, Arthur Grace and explained the purpose of the visit.

Regarding the allegation that there is a resident left in the bathroom for an extended period of time, according to the reporting party, staff are leaving resident #1 (R1) in the bathroom on the commode all day because she is “calm” in the bathroom. During the investigation, LPA visited the facility 3 times (6/16/2022, 9/8/2022, and 10/20/2022), however did not observe any residents in the bathroom or on a commode. In addition, interviewed staff indicated that only R1 requires assistance with using the bathroom, however, has not observed any staff leave R1 in the bathroom on a commode all day.

Based on observations and interviews conducted, the allegation resident left in the bathroom for an extended period of time 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.

Regarding the allegation that staff humiliate resident in public setting, according to the reporting party, Resident #2 (R2) masturbates constantly and the staff are giving R2 porn or humiliating R2 by calling him/her to watch a sexual scene on television to masturbate to. LPA interviewed staff and it was acknowledged that R2 does masturbate, however he/she masturbates in his/her room in private. In addition, interviewed staff indicated that they have not observed R2 masturbate in a public setting or get humiliated for masturbating.

Based on observations and interviews conducted, the allegation staff humiliate resident in public setting 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: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
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-20220609161732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: ARBOR HOUSE
FACILITY NUMBER: 415601122
VISIT DATE: 10/20/2022
NARRATIVE
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Regarding the allegation that unqualified staff are providing medications to residents without proper training, according to the reporting party, during interview with reporting party, it was indicated that unqualified staff are providing residents with medication without DSP (direct support professional) training. During the complaint investigation, LPA Charitra interviewed staff members, reviewed staff training records, and reviewed resident medication records and it was indicated that all staff who provide resident's medications are observed to have their DSP training.

Based on the interviews conducted, records reviewed, and information collected, the allegation that unqualified staff are providing medications to residents without proper training 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 Caregiver, Arthur Grace and a copy is provided with appeals rights. Caregiver refused to sign.n
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20220609161732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARBOR HOUSE
FACILITY NUMBER: 415601122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/27/2022
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).

Violation of this regulation is evidenced by:
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Facility Administrator/Licensee is constantly working on hiring staff members to meet program designed. Administrator will submit LPA a written plan on how facility can meet program designed
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Based on observations, LPA visited the facility on 9/8/2022 and 10/20/2022 and observed 2 staff members present during the AM shift. In addition, interviewed staff indicated there are normally 2 staff members present during the AM shift.
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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: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4