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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601122
Report Date: 09/13/2023
Date Signed: 09/13/2023 02:02:09 PM

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
12/09/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221209144007
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:
09/13/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:VeronicaTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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- Facility staff are drinking alcohol at the facility
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings into the allegations received. LPA met with administrator Victoria Alejandro and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews and made observations. Interviews conducted revealed that the above allegation did take place. This discovery was made by a facility manager who made a late night visit to the facility around 10:45pm and discovered the staff persons S2, S3, and S4 in the garage of the facility playing loud music and observing a bottle of alcohol and cups present. These staff persons and other staff persons employed at this time were terminated, or resigned, for not reporting these items to the administrator. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Report is reviewed with the administrator Victoria Alejandro.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 3
Control Number 14-AS-20221209144007
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: 09/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/14/2023
Section Cited
CCR
87468.1(a)(2)
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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.
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Facility terminated S2, S3, and S4 shorty after the incident occurred. In-service training to be conducted regarding staff conduct policies and reporting of incidents among staff. A sign in sheet and materials are to be submitted to the Department to show the trainings took place.
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This regulation has not been met as evidenced by: According to interviews S1 discovered during a night time unannounced visit to the facility 3 staff persons, S2, S3, and S4 in the garage of the facility with alcohol, cups, and music playing.
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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: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
12/09/2022 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221209144007

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:
09/13/2023
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Victoria AlejandroTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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- Facility staff uses facility van for inappropriate reasons
- Facility staff handled resident in a rough manner
- Facility staff inappropriately handled residents
- Facility staff cooks food for themselves using the facility's resources
- Facility staff allowed a resident to smell their cigarettes and feet
- Facility staff are out of ratio
- Facility staff does not follow a menu
- Facility staff sleep at the facility
- Facility administrator is not at the facility a sufficient amount of time
INVESTIGATION FINDINGS:
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On this day Licensings Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings into the allegations received. LPA met with Victoria Alejandro and explained the purpose of today's visit.

During interviews LPA was not able to confirm or deny if any of the allegations took place. LPA attempted to reach previous staff members but did not recieve any follow up contact from those staff persons. The current staff in the facility are new and have no knowledge of what happened previously in the facility. Perponderance of evidence standard could not be met on these allegations. These allegations are unsubstantiated.

Based on these observations, 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 is reviewed with administrator Victoria Alejandro.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
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 3