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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 03/07/2025
Date Signed: 03/07/2025 10:54:10 AM

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
02/11/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250211164016
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: 69DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
11:02 AM
ALLEGATION(S):
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Resident's dresser is inaccessible
Staff did not maintain a comfortable temperature for a resident in care.
INVESTIGATION FINDINGS:
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On March 7, 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, residents dress is inaccessible, according to the reporting party, Resident 1's (R1's) bed is pushed against the dresser and R1 is unable to use it to put his/her clothing inside of it.

During the investigation, LPA observed R1's room and observed R1's dresser against R1's bed and LPA was unable to fully open the dresser.

Regarding the allegation, staff did not maintain a comfortable temperature for a resident in care, according to the reporting party, it was reported that there is no heat in R1's room since being admitted in December of 2024. (Continue to 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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
Control Number 14-AS-20250211164016
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: 03/07/2025
NARRATIVE
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During the investigation, LPA toured the facility and R1's room. Based on observations, there was no functioning heating unit in R1's room and there were no space heaters that were provided. In addition, during the facility tour, LPA observed that the second floor communal area had no functioning heating units, however there were space heaters in the room. LPA observed space heaters in certain residents rooms due to no functioning heating unit. According to the administrator, there has been issues with some of the HVAC units and facility currently looking for repairs.

Based on information collected and observations conducted, the preponderance of evidence standard has been met, therefore the above allegations are 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.

Report is reviewed with Administrator and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
02/11/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250211164016

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: DATE:
03/07/2025
UNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
11:02 AM
ALLEGATION(S):
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Staff did not properly transfer a resident in care resulting into a injury
Staff did not seek medical attention in a timely manner.
Staff did not transport resident to a medical appointment.
INVESTIGATION FINDINGS:
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On March 7, 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, staff did not properly transfer a resident in care resulting into an injury, according to the reporting party, on 01/22/25, the staff took Resident 1 (R1) to take a shower and when the staff transferred R1 to the shower chair, they dropped him/her.

During the investigation, LPA reviewed R1's records and interviewed staff. Based on R1's assessments, R1 requires one person total assist with bathing. According to staff interviewed, there were two staff members present to assist R1 to shower. While transferring R1 from the wheelchair to the shower, R1 slipped and fell, however staff indicated they tried to break R1's fall.

Regarding the allegation, staff did not seek medical attention in a timely manner and staff did not transport a resident to a medical appointment, after an incident that occurred on 1/22/25, R1 was in pain and requested staff to call 911 but staff did not call and R1 has not been taken to see the doctor. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
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 5
Control Number 14-AS-20250211164016
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: 03/07/2025
NARRATIVE
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During the investigation, LPA interviewed staff. According to staff interviewed, R1 was asked multiple times if he/she wanted to go to the hospital and if he/she wanted the facility to call 911, however R1 refused and didn't want his/her family members to know.

Regarding the allegation, staff did not transport resident to a medical appointment, according to the reporting party, R1 had an appointment on 2/10/25 for his/her pain, however the staff did not take R1 because his/her appointment was too far.

During the investigation, LPA interviewed the Administrator and reviewed the transportation log located at the front desk. According to the administrator, if a resident has an appointment, they are required to notify the front desk 72 hours in advance to ensure a drive is available for transportation. In addition, according to the administrator R1 did not notify the facility on his/her appointment until the morning of her appointment. Based on the transportation log, LPA did not observe R1's name listed on the log for 2/10/25. Furthermore, LPA reviewed the resident handbook that is provided by the facility which indicates, to reserve a ride with the front desk receptionist at least 72 hours in advance.

Based on 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: 03/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20250211164016
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: 03/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/14/2025
Section Cited
CCR
87468.1(a)(13)
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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: (13)To have access to individual storage space for private use.

This requirement is not met as evidenced by:

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Deficiency is cleared during the visit. LPA observed R1's room and observed R1 to have access to dresser.
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LPA observed R1's room and observed R1's dresser against R1's bed and LPA was unable to fully open the dresser which poses a potential health and safety risk for residents in care.
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Type B
03/07/2025
Section Cited
CCR
87303(b)
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87303 Maintenance and Operation: (b) A comfortable temperature for residents shall be maintained at all times.

This requirement is not met as evidenced by
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Licensee/Administrator shall submit a plan in writing indicating how to ensure a comfortable temperature is maintained at the facility. Plan shall include repairing heating units.
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Based on interviews and observations, the facility does not have working heating units in some parts of the facility. According to the administrator, there has been issues with some of the HVAC units and facility currently looking for repairs, however for the meantime, residents are being provided space heaters as an alternative option.
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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: 03/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5