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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601165
Report Date: 09/10/2025
Date Signed: 09/10/2025 01:49:29 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
06/05/2025 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250605210627
FACILITY NAME:GENERATIONS CARE HOMEFACILITY NUMBER:
415601165
ADMINISTRATOR:MEHTA, IRENEFACILITY TYPE:
740
ADDRESS:859 CAMARITAS CIRTELEPHONE:
(650) 438-6710
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Irene MehtaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Residents are not accorded dignity and respect
Staff used restraint for resident
INVESTIGATION FINDINGS:
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On 9/10/2025, LPA Grace Donato conducted an unannounced complaint investigation visit to deliver findings. LPA met with Administrator, Irene Mehta and explained the purpose of this visit.

Regarding the allegation of Residents are not accorded dignity and respect and staff used restraint for resident, Responsible party (RP) stated that ADM informed a witness (W1) that the staff used mitten restraints while changing and feeding the resident (R1). W1 told ADM that restraints were not allowed.

During the investigation, the ADM mentioned using mittens whenever they change R1s diapers because R1 is very combative. The mittens was provided by the family members. While there was a consent provided by the family members, there was no Doctors order when LPA requested it from the facility.

Based on interview, the above allegations are determined 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 and copy of the report and appeals rights are provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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
Control Number 14-AS-20250605210627
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: GENERATIONS CARE HOME
FACILITY NUMBER: 415601165
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2025
Section Cited
CCR
87608(a)(5)
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87608 Postural Supports (a)Based on the individual's preadmission appraisal, and subsequent changes to that appraisal...Postural supports may be used under the following conditions.(5)Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.
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Licensee to submit an in-service training for staff regarding Postural Supports. Licensee to submit by POC deadline.
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This was not met as evidenced by:
Based on interviews, the facility put mittens on R1s hands whenever diaper changes happens, which poses an immediate Health, Safety, or Personal Rights risk to persons 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: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
06/05/2025 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250605210627

FACILITY NAME:GENERATIONS CARE HOMEFACILITY NUMBER:
415601165
ADMINISTRATOR:MEHTA, IRENEFACILITY TYPE:
740
ADDRESS:859 CAMARITAS CIRTELEPHONE:
(650) 438-6710
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 5DATE:
09/10/2025
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Irene MehtaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not provide information to emergency personnel about the resident
Facility did not give reimbursement upon move out
Residents are not allowed privacy
INVESTIGATION FINDINGS:
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Regarding the allegation of Facility did not give reimbursement upon move out, RP stated that a reimbursement for the month of April was not provided since R1 was moved out on April 8th, 2025.

Based on records review, it was not clear on the Admissions Agreement that a refund is to be provided if the residents move out before the 30 day notice ends. It just states that the resident/responsible party only must provide a 30-day notice.

Due to the agreement not clear, the ADM will provide a reimbursement that is prorated based on the last day of which all belongings are removed from the facility.

Regarding the allegation of staff did not provide information to emergency personnel about the resident, RP stated that Law Enforcement went to the facility when EMT called to report that ADM was not providing information about the resident (R2).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
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 4
Control Number 14-AS-20250605210627
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: GENERATIONS CARE HOME
FACILITY NUMBER: 415601165
VISIT DATE: 09/10/2025
NARRATIVE
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According to the interview, ADM provided the information requested during this time. The EMTs didn’t want to talk to the family, but kept asking about the DPOA. The ADM of whom was on the phone with the family during this time with a three way with the case worker (CW) during the incident. The family was asking why the R2 needed to go to the hospital. LPA tried to reach DPOA but has not gotten any reply. CW confirmed that they were in a phone call about the resident being sent to the hospital.

Based on records review, LPA obtained a police report, and it states that the Fire Captain were waiting for pertinent patient information that ADM was refusing to provide and acting aggressive. Police asked ADM to retrieve the paperwork but ignored the request. ADM was uncooperative, and verbally aggressive, providing several reasons why she refused to provide the necessary information. She eventually obtained and provided the information to the Fire Captain, but only after requesting the information from her numerous times. LPA has also obtained message exchanges between ADM and Social worker, working on managing R2s behaviors.

Regarding the allegation of residents are not allowed privacy, RP states that staff said residents doors must remain open.

Based on observations, LPA observed that there are rooms where the doors remain open. One resident (R3) had the door closed and just rings the bell if he/she needs anything. At the same time the staff does rounds and checks on them from time to time.

LPA attempted to interview 3 residents but didn't want to be interviewed.

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

Report is reviewed and copy is provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4