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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601122
Report Date: 08/28/2023
Date Signed: 08/28/2023 02:29:18 PM

Unsubstantiated


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
08/21/2023 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 14-AS-20230821141221
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:
08/28/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Victoria AlejandroTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Administrator is not present on the premises a sufficient number of hours to manage the facility
INVESTIGATION FINDINGS:
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On 8/28/2023, Licensing Program Analyst (LPA) Grace Donato Grace Donato conducted an unannounced 10-day complaint inspection. LPA Donato met with Administrator, Victoria Alejandro. LPA Donato explained the purpose of the visit.

Regarding the allegation that Administrator (S1) is not present on the premises with a sufficient number of hours to manage the facility. Reporting party (RP) stated that S1 is not present to provide adequate attention to the management and administration of the facility.

LPA conducted interviews and reviewed documents regarding S1 and the allegations. Two out of two staff members interviewed stated that administrator works at facility and sometimes covers other caregivers who would call out. Interviews confirm that S1 comes to the facility to help manage and do admin work. Based on documents provided, while S1 may not be on the premises there is a designated responsible person who oversees the facility. This allegation is unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
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
Control Number 14-AS-20230821141221
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: 08/28/2023
NARRATIVE
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Based on these observations, interviews & record reviews, 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.

Report discussed with administrator and a copy is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2