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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601233
Report Date: 06/17/2026
Date Signed: 06/17/2026 12:01:24 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
06/16/2026 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20260616081457
FACILITY NAME:HARBOR AT HILLSDALE SENIOR LIVINGFACILITY NUMBER:
415601233
ADMINISTRATOR:JASMINE SEIFFERTFACILITY TYPE:
740
ADDRESS:2883 S NORFOLK STTELEPHONE:
(707) 592-4252
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:175CENSUS: 88DATE:
06/17/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator - Jasmine SeiffertTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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- Staff did not treat residents in care with dignity and respect
INVESTIGATION FINDINGS:
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On 06/17/2026, Licensing Program Analyst (LPA) Jaime Vado conducted an uannounced complaint inestigation visit in regards to the allegation received. LPA met with administrator Jasmine Seiffert and explained the purpose of today's visit.

During the course of the investigation, LPA interviewed staff, reviewed pertinent documentation, video evidence, and attempted to interview residents. The facility self reported an incident on 06/03/2026 via incident report to the Department after discovering the video being sent to them from an outside source. The video evidence reviewed by the Department shows a staff person harassing residents in care. In response to this, the facility conducted training in personal rights, elderly abuse, and reporting requirements, and terminated the staff member as this posed an immediate health and safety risk to residents in care. Based on the evidence reviewed this allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with the administrator and a copy is provided on this day. Appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 14-AS-20260616081457
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: HARBOR AT HILLSDALE SENIOR LIVING
FACILITY NUMBER: 415601233
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/18/2026
Section Cited
CCR
87468.1(a)(1)
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87468.1(a)(1) - Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This regulation has not been met as evidenced by:
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The facility shall conduct an in-service training with staff regarding: Resident Rights, including abuse, and reporting requirements. Evidence of such training to be recieved by due date.
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Based on video evidence reviewed, this regulation has not been met. The video evidence shows a staff person harrassing residents in care, which is not according them dignity or respect with their relationships but staff. This poses an immediate health and safety risk.
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POC has been received as the facility had conducted such training in response to the incident.
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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.
SUPERVISOR'S NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
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