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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 02/24/2025
Date Signed: 02/24/2025 12:45:27 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
11/20/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241120141233
FACILITY NAME:SERRA HIGHLANDS SENIOR LIVINGFACILITY NUMBER:
415601127
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:501 KING DRIVETELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 70DATE:
02/24/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator, Shayan Gheisar TIME COMPLETED:
12:55 PM
ALLEGATION(S):
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Three resident's eloped due to lack of supervision
INVESTIGATION FINDINGS:
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On February 24, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit.

Regarding the allegation, three residents eloped due to lack of supervision, according to the reporting party, four residents have eloped from the facility due to lack of supervision.

During the investigation, LPA interviewed administrator and staff. According to administrator and staff, there was a resident (R1) who did leave the facility unassisted once and was found by a caregiver and redirected back to the facility. Based on R1's physician's report reviewed, it was noted R1 had a diagnosis of dementia and is unable to leave the facility unassisted. Family was informed and facility helped family move R1 to a memory care facility.

Based on information collected and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Failure to correct said deficiencies may result in additional civil penalties. An immediate $500.00 is issued due to absence of supervision. Report is reviewed with Administrator and a copy is provided with appeal rights. Copy of civil penalty is provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
11/20/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241120141233

FACILITY NAME:SERRA HIGHLANDS SENIOR LIVINGFACILITY NUMBER:
415601127
ADMINISTRATOR:SHAYAN GHEISARFACILITY TYPE:
740
ADDRESS:501 KING DRIVETELEPHONE:
(650) 878-5111
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:120CENSUS: 70DATE:
02/24/2025
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator, Shayan Gheisar TIME COMPLETED:
12:55 PM
ALLEGATION(S):
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-Administrator is not at the facility the required minimum hours a week
-Resident's toilet has been broken for three weeks
-Facility does not meet residents' nutritional needs
-Staffing levels do not meet the needs of residents in care
-Staff are not trained to meet the needs of residents in care
-Facility is not notifying residents and families of changes taking place in licensee or coporate structure
INVESTIGATION FINDINGS:
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On February 24, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Shayan Gheisar and explained the purpose of the visit.

Regarding the allegation, administrator is not at the facility the required minimum hours a week, according to the reporting party, the administrator is not at the facility enough hours a week due to being the administrator at the sister facility of the company Pacifica Senior Living Mission Villa and is non-responsive.

During the investigation, LPA interviewed staff and reviewed LIC500 (Personnel Report). Based on the LIC500 reviewed, it indicated that the administrator works Monday-Tuesday at one facility and Wednesday-Friday at the sister community then alternates the following week. According to staff members interviewed, they indicated that the administrator is at the facility a sufficient number of hours a week and is responsive.

Regarding the allegation, resident's toilet has been broken for three weeks, according to the reporting party, Resident 1's (R1's) toilet has not been functioning for 3 weeks and has been an ongoing issue. (Continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
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 5
Control Number 14-AS-20241120141233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SERRA HIGHLANDS SENIOR LIVING
FACILITY NUMBER: 415601127
VISIT DATE: 02/24/2025
NARRATIVE
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During the complaint visit, LPA observed R1's toilet to be in good working condition. Based on interview conducted with R1, the facility replaced his/her toilet with a new toilet. According to the administrator, the facility was having plumbing issues throughout the facility, however it has been fixed as all the toilets are in good working condition.

Regarding the allegation, facility does not meet residents' nutritional needs, according to the reporting party, the facility's food quantity and quality are not adequate to meed the nutritional needs of the residents and the facility does not give the residents enough food to meet those nutritional needs. In addition, the reporting party indicated, the facility sometimes runs out of food.

During the investigation, LPA interviewed residents, observed the facility's food menu and observed the facility's food supply. LPA observed 2 day perishables and 7 day non-perishables present at the facility. LPA observed one weeks food menu and observed that the facility provides several entree options each meal with additional daily items and snacks to choose from. Kitchen staff have record of resident dietary restrictions with notation of restrictions labeled on the menu for each individuals' diet. Upon interviews with residents, LPA received inconsistent information regarding food taste but was found that the facility provides 3 meals a day with a variety of nutritious food options.

Regarding the allegation, staffing levels do not meet the needs of residents in care, according to the reporting party, staffing levels present are not enough to meet the needs of residents by not responding to residents timely and providing the actual services when appropriate.

During the investigation, LPA reviewed staff schedule, 5 residents response times. According to the administrator, there are 6 caregivers for 70 residents during the morning and afternoon shift, 11 of which are independent resident. LPA reviewed 5 residents call buttons within the last months, and on average the response time is 7 minutes.

Regarding the allegation, staff are not trained to meet the needs of residents in care, according to the reporting party, staffing levels present are not enough to meet the needs of residents and the staff are not trained properly to meet those needs by not responding to residents timely and providing the actual services when appropriate. (Cont to 9099C).
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20241120141233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SERRA HIGHLANDS SENIOR LIVING
FACILITY NUMBER: 415601127
VISIT DATE: 02/24/2025
NARRATIVE
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During the visit, LPA reviewed 5 staff files and observed training records. Staff records are complete, with training logs that have met the basic requirement. On going staff training is provided monthly regarding the following topics; infection control, proper transferring, incontinence care, skin checks, first-aid, etc.

Regarding the allegation, facility is not notifying residents and families of changes taking place in licensee or corporate structure, according to the reporting party, there are changes being made on the corporate level, or ownership level, and those changes are not being communicated to residents and the families of the residents.

During the investigation, LPA interviewed responsible parties, administrator, business office manager, and reviewed documents. The administrator and the business office manager denied this allegation and indicated that a letter was sent to residents and family members on October 1, 2024 notifying them that there will be a change in management company. Administrator provided LPA a copy of the letter for review. According to residents interviewed, it was indicated that they did receive letters from the facility notifying them of the change of management.

Based on observations, documents reviewed, and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with the administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20241120141233
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SERRA HIGHLANDS SENIOR LIVING
FACILITY NUMBER: 415601127
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/25/2025
Section Cited
CCR
87464(f)(1)
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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee/administrator to conduct in-service training regarding elopment risks and how to ensure there is adequate supervision.
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Based on staff interviews, there was a resident (R1) who did leave the facility unassisted once and was found by a caregiver and redirected back to the facility. Based on R1's physician's report reviewed, it was noted R1 had a diagnosis of dementia and is unable to leave the facility unassisted which poses an immediate health and safety risk for residents in care.
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Immediate Civil Penalty of $500.00 is being assessed today 2/24/25 for absence of supervision.
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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: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5