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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 06/17/2025
Date Signed: 06/17/2025 10:54:31 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
05/14/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250514093527
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:
06/17/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Staff do not ensure resident's record is up to date.
INVESTIGATION FINDINGS:
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On June 17, 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, staff do not ensure resident's record is up to date, according to the reporting party, Resident 1 (R1) has not seen his/her primary care physician (PCP) in 3 years and records are not up to date.

During the investigation, LPA reviewed R1’s file and observed R1’s physician’s report to be from 9/2021. R1 does not have an updated physician’s report as according to the administrator, R1 has not seen his/her PCP or seen a physician since 2021.

Based on information collected and file reviewed, 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.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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 4
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
05/14/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250514093527

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:
06/17/2025
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Shayan GheisarTIME COMPLETED:
11:05 AM
ALLEGATION(S):
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Staff do not ensure resident is provided food service.
Staff do not ensure resident attends medical appointments.
Staff are not properly trained.
Staff do not ensure facility restrooms have adequate toiletry supplies.
Staff is retaining a resident that requires a higher level of care.
INVESTIGATION FINDINGS:
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On June 17, 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 do not ensure resident is provided food service, according to the reporting party, Resident 1 (R1) is not being brought lunch into his/her room and/or not being brought to the dining hall for meals.

During the investigation, LPA interviewed the administrator, staff and reviewed the meal tracking log. Based on the log reviewed and interviewed staff, R1 is being provided three meals a day whether he/she is in the dining hall or in his/her room, however there are times where R1 does refuse to eat meals but Ensure is provided to R1.

Regarding the allegation, staff do not ensure resident attends medical appointments, according to the reporting party, R1 has not been seen by his/her primary care physician (PCP) in 3 years. According to the reporting party, R1’s friend used to take R1 to medical appointments, however because R1’s friend can’t take R1 to his/her medical appointments, R1 has not been attending to medical appointments. (continue to 9099C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
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 4
Control Number 14-AS-20250514093527
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: 06/17/2025
NARRATIVE
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During the visit, LPA interviewed the administrator and med-tech. According to the administrator and med-tech, it’s the residents and responsible parties responsibility to schedule the medical appointments. In addition, administrator and med-tech indicated that once responsible parties or residents schedule medical appointments, they should notify the front desk so that transportation can be arranged in advance.

Regarding the allegation staff are not properly trained, according to the reporting party, he/she spoke to a med-tech (name unknown) that was not sure who was filling R1's medications and did not know much about R1.

During the investigation, LPA reviewed 5 staff training records. LPA concluded that based off the records of staff training, staff are being trained regularly throughout the year. Staff records are complete and training logs are being maintained and audited every month.

Regarding the allegation, staff do not ensure facility restrooms have adequate toiletry supplies, according to the reporting party, the communal bathrooms at the facility does not have toilet paper, liquid soap, and paper-towels.

During the visit, LPA interviewed housekeeping staff and observed the communal bathrooms. According to the housekeeping staff, the bathrooms are checked and toiletries are restocked in all communal bathrooms at the start of their shift in the morning and then checked 3x throughout the day. During the investigation, LPA observed the two communal bathrooms on the first floor and the communal bathroom on the second floor and observed all three bathrooms to be equipped with liquid soap, paper towels, toilet seat covers, and paper-towels.

Regarding the allegation, staff is retaining a resident that required a higher level of care, according to the reporting party, R1 has advanced dementia based on the medications R1 is taking for Alzheimer’s dementia, however there is no memory care services at the facility.

During the investigation, LPA observed R1’s file and medication list. Although R1 is taking two alzheimer's dementia medications, the facility does not have anything in writing indicating that R1 has dementia. According to the administrator, the facility has tried several times to reach out to R1's responsible party to schedule an appointment for R1 to be reassessed, however R1's responsible party is non-responsive.

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: 06/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20250514093527
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: 06/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/24/2025
Section Cited
CCR
87463(h)
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87463 Reappraisals: (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
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Licensee/administrator shall ensure all residents are receiving annual visits and documentation is maintained in each resident's file. In addition, administrator/licensee shall ensure if residents refuse annual appointments or responsible parties fail to be responsive, it gets documented.
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Based on records reviewed, R1 has not received an annual routine visit since 9/2021 which poses a potential health and safety risk to residents in care.
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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: 06/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4