Complaint Investigation Report

415601137-2-19-2025-14-AS-ACON-DEF3DA-20250303170913

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

SAN BRUNO RO , 851 TRAEGER AVE., SUITE 360

This is an official report of an unannounced visit/investigation of a complaint received in our office on

01/29/2025 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20250129110008

Licensee is not ensuring that the facility has sufficient staff to meet the needs of residents in care.

On 2/19/2025 Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit at the facility. LPA met with Administrator Susan Tilma and explained the purpose of the visit.

Regarding Licensee is not ensuring that the facility has sufficient staff to meet the needs of residents in care, according to the reporting party, there are 5 residents at the facility and either 1 or 2 staff members present at to provide care and supervision throughout the day.

During the complaint visit on 1/31/25, LPA observed 5 residents in their beds and one staff member (S1) cooking breakfast. LPA reviewed all 5 resident files and observed 4/5 residents to have a diagnosis of dementia and one resident that is on hospice. According to the administrator and S1, from 8-9am, S1 is providing care and supervision to the 5 residents. When S1 goes on his/her break from 11am-1pm, there is another staff member (S2) who is providing care and supervision to 5 residents alone.

Therefore, based on the interviews conducted and information collected, 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. A copy of the report and appeal rights are provided.