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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 03/13/2026
Date Signed: 03/13/2026 02:20:02 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
02/27/2026 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260227122349
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: 50DATE:
03/13/2026
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Resident Services Director, Anne DasmarinasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not properly trained
INVESTIGATION FINDINGS:
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On March 13, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Resident Services Director, Anne Dasmarinas and explained the purpose of the visit.

Regarding the allegation, staff are not properly trained, according to the reporting party, there have been multiple medication administration errors occurring during the NOC shift after a care staff members was assigned to perform Med-Tech duties without documented medication training.

During the investigation, LPA interviewed the Resident Services Director and reviewed training records for all 7 med-techs. According to the Resident Services Director, she reviewed med-techs training records. On 3/6/26, after she discovered Staff 1 (S1), who is a med-tech, did not complete their initial training to assist residents with self-adminisration of medications, she pulled S1 off the schedule. On 3/11/26, after the Resident Services Director discovered Staff 2 (S2), another med-tech, did not complete their initial training to be able to administer medications to residents, she pulled S2 off the schedule. (continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
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-20260227122349
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: 03/13/2026
NARRATIVE
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 Based on training records reviewed, there are 7 med-techs in total and both S1 and S2 did not complete their 16 hours of initial training prior to administering medications to residents in care. In addition, based on training records reviewed, LPA did not observe med-techs receiving their annual on-the-job training in relation to policies and procedures regarding medications on top of their initial required training to be able to administer medication to residents in care. The facility was unable to provide me any documentation to show med-techs are receiving their annual on-the-job training.

Based on information collected and files 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.

Report is reviewed with Resident Services Director and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 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
02/27/2026 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260227122349

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: 50DATE:
03/13/2026
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Resident Services Director, Anne DasmarinasTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff mishandled the residents medications
INVESTIGATION FINDINGS:
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On March 13, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Resident Services Director, Anne Dasmarinas and explained the purpose of the visit.

Regarding the allegation, staff mishandled the residents medication, according to the reporting party, Resident 1 (R1) did not receive levothyroxine on 2/4/26-2/5/26 and alendronate was administered four consecutive days beginning 2/16/26, although R1’s order was once a week.

During the investigation, interviewed staff and LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1’s medication list as prescribed by the physician and the medication bottle, R1 is required to take one tablet of Levothyroxine (88mcg) daily, 30 minutes before breakfast. LPA reviewed R1’s MAR for 2/4/26-2/5/26 and it showed that Levothyroxine was administered on 2/4/26 at 7:11AM and on 2/5/26 at 7:16AM. (Continue to 9099C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
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-20260227122349
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: 03/13/2026
NARRATIVE
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LPA conducted a medication count for R1’s Levothyroxine. LPA observed the amount of medications in the bottle corresponded with the start date of the medication listed on the centrally stored medication record. In addition, according to staff interviews, R1 does not take alendronate. LPA confirmed that alendronate is not on the R1’s prescribed medication list and MAR.

Based on documents reviewed, information collected, observations, and interviews conducted, the department has determined that although the above allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the above allegation is UNSUBSTANTIATED.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20260227122349
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: 03/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2026
Section Cited
HSC
1569.69(a)(1)
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§1569.69 Employees assisting residents with self-administration of medication; training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 16 hours of initial training... This training shall consist of eight hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medication which shall be completed within the first two weeks of employment.
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Licensee/administrator shall submit a plan in writing on how to ensure all med-techs complete their initial 16 hours of training. Plan shall include, documented how many hours it took to complete the training.
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This requirement is not met as evidenced by: Based on training records reviewed, S1 and S2 did not have their initial 16 hours of training documented prior to administering medication to residents in care which poses an immediate health and safety risk to residents in care.
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Type A
03/14/2026
Section Cited
CCR
87411(c)(3)(D)
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87411 Personnel Requirements - General: (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69 (3) The training shall include, but not be limited to, the following:(D) Policies and procedures regarding medications, including the knowledge in Section 87411(d)(4).

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Licensee/administrator shall submit a plan in writing on how to ensure all staff receive their annual on-the-job training. Plan shall include; who will be conducting the training, when it will be conducted, keeping track of staff that require their annual training, maintaining documentation of the training, etc.
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This requirement is not met as evidenced by: The facility was unable to provide LPA documentation to show med-techs have been receiving their annual on-the-job training. LPA did not observe any annual trainings in med-techs files during file review.
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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 Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5