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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601127
Report Date: 04/28/2026
Date Signed: 04/28/2026 03:08:27 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
02/26/2026 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260226120348
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: 47DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator, Joshua LambengcoTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff do not ensure the facility is free of odor
INVESTIGATION FINDINGS:
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On April 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit.

Regarding the allegation, staff do not ensure the facility is free of odor, according to the reporting party, Resident 1's (R1's) room had a strong odor consistent with urine.

During the investigation, LPA toured and observed R1's room. R1's room smelled like urine and LPA observed stains on R1's carpet.

Based on observations, 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. A civil penalty of $250.00 is being issued during the visit for a repeat citation within 12 months. Deficiency was cited on 2/18/26. This report is reviewed and discussed with the Administrator; a copy is provided. 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 Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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 4
Control Number 14-AS-20260226120348
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: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/05/2026
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by
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Based on observations made during complaint visit on 4/28/26, the carpet was replaced with hardwood floors and the room was aired out and no longer smelled like urine. Deficiency cleared and corrected.
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Based on observations, R1's room smelled like urine and LPA observed stains on R1's carpet which poses a potentional health and safety risk to residents in care.
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A civil penalty of $250.00 is being issued during the visit for a repeat citation within 12 months. Deficiency was cited on 2/18/26.
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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: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 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
02/26/2026 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260226120348

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: 47DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Administrator, Joshua LambengcoTIME COMPLETED:
03:25 PM
ALLEGATION(S):
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Staff did not ensure resident was adequately fed
Staff do not ensure the residents toileting needs are met
Staff refused to assist resident with dressing
Staff did not ensure resident wound care needs were met
Staff did not ensure resident's hygiene needs were met
INVESTIGATION FINDINGS:
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On April 28, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced complaint visit. LPA met with Administrator, Joshua Lambengco and explained the purpose of the visit.

Regarding the allegation, staff did not ensure reisdent was adequately fed, according to the reporting party, it was observed that Resident 1 (R1) was still in bed and had not yet eaten breakfast at around 10:30am. During the investigation, LPA interviewed staff, reviewed R1's file, and attempted to interview R1's responsible party. According to R1's service plan reviewed dated 10/23/25, R1 is independent with meals, eats all meals in the dining room, and is independent with food choices. Based on R1's physician's report dated 3/11/25, R1 is able to feed himself/herself, LPA was unable to interview R1 as R1 is no longer a resident at the facility and R1's responsible party was not responsive. According to staff interviewed, R1 would eat all his/her meals in the dining hall and if for some reason he was not at the dining hall, meal trays would be delivered to his/her room, however most of the time, R1 would be at the dining hall and never refused meals. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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 4
Control Number 14-AS-20260226120348
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: 04/28/2026
NARRATIVE
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Regarding the allegation, staff do not ensure the residents toileting needs are met and staff refused to assist resident with dressing, according to the reporting party, R1 did not have available diapers in his/her personal supply bag, and the diapers present were not appropriately sized for R1. Staff were asked for assistance in dressing R1 prior to discharge, however staff declined stating R1 was able to dress himself/herself. I requested staff assistance in helping Mr. Hill dress prior to discharge; staff declined, stating that he was able to dress himself.

During the investigation, LPA interviewed staff, reviewed R1's file and attempted to interview R1's responsible party. LPA was unable to interview R1 as R1 is no longer a resident at the facility and R1's responsible party was not responsive. Based on R1's physician's report dated 3/11/25, R1 is able to dress himself/herself and care for his/her own toileting needs. According to R1's service plan dated 10/23/25, R1 is independent with dressing and toileting tasks. Based on staff interviews, R1 was assisted with dressing and changing of his/her diaper as R1 would wet himself/herself. Staff indicated if a resident is independent with toileting and dressing, however a resident needed assistance, staff would always help. In addition, staff indicated, there were always extra diapers at the facility and previous staff were in charge of ordering it for R1.

Regarding the allegation, staff did not ensure resident wound care needs were met and staff did not ensure resident's hygiene needs were met, according to the reporting party, during hygiene care at R1's new facility, staff observed significant physical concerns, including large open wounds on R1's back, scabbing and wounds present on ears, overgrown toenails, and fingernails with visible debris underneath. R1's hair and facial hair were overgrown, and his/her overall presentation was consistent with poor hygiene.

During the investigation, LPA interviewed staff, reviewed R1's file and attempted to interview R1's responsible party. LPA was unable to interview R1 as R1 is no longer a resident at the facility and R1's responsible party was not responsive. Based on R1's physician's report dated 3/11/25, R1 is able to bathe and groom himself/herself. According to R1's service plan dated 10/23/25, R1 is one persons assist with showers and received showers every Monday and Friday in the PM. Based on staff interviews, staff were not aware of any wounds that R1 had while at the community. Staff indicated that R1 would receive showers 1-2x a week, however at times R1 would refuse.

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

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4