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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600399
Report Date: 06/04/2021
Date Signed: 06/04/2021 03:22:46 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/03/2021 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210603093213
FACILITY NAME:SAN FRANCISCO RCFEFACILITY NUMBER:
385600399
ADMINISTRATOR:ADELA MORALESFACILITY TYPE:
740
ADDRESS:887 POTRERO AVENUETELEPHONE:
(628) 206-6436
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:59CENSUS: 38DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Claudia MoralesTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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9
Staff not using proper PPE.
Staff are mishandling medications.
INVESTIGATION FINDINGS:
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On 06/04/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up on-site complaint inspection visit with Director of Behavioral Health Center Linda Sims and Administrator Adela Morales. The 10-day visit was conducted under the wrong facility number. LPA Filouane has transferred the allegations to the correct facility number. LPA explained the purpose of the visit and then delivered the findings.

Concerning the allegation of staff not using proper PPE, LPA Filouane interviewed the Administrator, staff members, and the complainant. The complainant states that on a date that is undetermined, a resident went up to the snack room fridge and asked a staff member to reach for a piece of cake. The complainant states the staff member was not wearing gloves. The staff member in an interview with the LPA states they were wearing one glove on one hand and no glove on the other hand. In an interview with the complainant, the complainant stated they witnessed the staff member not wearing gloves but also stated not remembering the details or events that occurred that day. One of the staff members acknowledged that they were only wearing one glove on one hand while not wearing a glove on the other hand when handling the pre-packaged cake. According to the local public health department, there is not a regulation or guideline addressing gloves being worn on one hand. After review, this allegation is unfounded.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/03/2021 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210603093213

FACILITY NAME:SAN FRANCISCO RCFEFACILITY NUMBER:
385600399
ADMINISTRATOR:ADELA MORALESFACILITY TYPE:
740
ADDRESS:887 POTRERO AVENUETELEPHONE:
(628) 206-6436
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:59CENSUS: 38DATE:
06/04/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Claudia MoralesTIME COMPLETED:
02:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff acting aggressively.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/04/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted an on-site follow-up complaint inspection visit with Director of Behavioral Health Center Linda Sims and the Administrator Adela Morales. LPA explained the purpose of the visit and then delivered the findings.

Concerning the allegation of staff acting aggressively, the complainant stated that the staff member's body language was aggressive; however, the complainant could not remember details or events that occurred on that day. Originally, the complainant stated that staff had lunged to the door and kept trying to slam it in the resident’s face. In staff interviews, staff 1 (S1) and staff 2 (S2) stated the door of the snack room is heavy and that the door can easily slam shut with a light push. S1 denies acting aggressive or slamming the door on the resident. Based on the interviews that the LPA conducted, there is not enough information and evidence found to prove staff acted aggressive. After review, this allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with the Administrator and Director of Behavioral Health Center.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2021
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 3
Control Number 14-AS-20210603093213
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAN FRANCISCO RCFE
FACILITY NUMBER: 385600399
VISIT DATE: 06/04/2021
NARRATIVE
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Concerning the allegation of staff mishandling medications, LPA interviewed the Administrator, staff members, and the complainant. The allegation alleges that staff would walk away from the medication cart and leave it alone. No further information was provided by the complainant. Staff members deny the allegation. It is noted that the complainant filed a previous complaint through a third party with an allegation that facility staff was mishandling medications (Complaint Control Number 14-AS-20210310114055). During that investigation, LPA Filouane interviewed the Administrator, staff members, residents, and reviewed medication records of residents. No issues were found. During this investigation, the complainant indicated to have a long list of allegations regarding the facility to be filed later. After review, this allegation is unfounded.

This agency has investigated the complaint alleging staff not using proper PPE and staff mishandling medications. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview conducted with the Administrator and Director of Behavioral Health Center.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3