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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600399
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:15:10 PM

Unsubstantiated


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
09/30/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210930110757
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: 40DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Administrator, Adela MoralesTIME COMPLETED:
01:20 PM
ALLEGATION(S):
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9
Resident needs a higher level of care
Residents are locked out the front door
INVESTIGATION FINDINGS:
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On 10/21/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannouced visit to deliver the investigtion findings. LPA Han met with the Administrator, Adela Morales and explained the purpose of the visit. LPA was properly screened by the receptionist at the main entrance.

Regarding to allegation of- resident needs a higher level of care- LPA Han observed residents in question and all of them are independent with their Activities of Daily Living (ADLs) and ambulation with the exception of one resident who requires some assistance with performing some of the ADLs due to a recent change of condition.

According to the Physician's Reports, all of them are able to leave the facility unassisted and they have the capacity for self-care. Furthermore, according to staff, all the residents in question are independent with their ADLs but some of them need a little reminder and encouragement and others need more such as Resident #3 (R3) who needs a lot of convincing and encouragement to perform personal hygiene tasks and overall room cleanliness. Base on observation, record review and interviews during the course of investigation, this allegation is unsubstantiated.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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
Control Number 14-AS-20210930110757
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: 10/21/2021
NARRATIVE
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Regarding to allegation of- residents are locked out the front door, the Reporting Party stated that Resident #1 (R1) and some of other residents are being locked out after leaving the facility from the front door and it is difficult for them to re-enter the facility from the main entrance especially with the residents who require medical device for ambulation as the main entrance is around the block.

According to R1, R1 does not use the front door. R1 uses the elevator and the facility's main entrance to exit and to enter the facility. According to Resident #2 (R2), locking the front door is not a problem as R2 uses the main entrance to come back to the facility.

According to the Director of the Behavioral Health Service Center, the front door was unlocked up until a few weeks ago as there were too many people congregating by the door and homeless people come in at night so the facility decided to lock the gate as people are leaving to ensure the safety of the residents and staff. In addition, the Director of Behavioral Health Service Center stated that the residents who ambulate with a medical device is being re-directed by the staff who monitors the exit door to take the elevator down to the 1st floor and then exit through the main entrance because it would be unsafe for them to exit from the front door as there are many stairs leading to the door. Base on observation and interviews during the course of investigation, this allegation is unsubstantiated.
.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

During the course of the investigation, LPA Han observed some documents did not reflect the current status of a resident. This deficiency will be cited on LIC809D.

This report is reviewed and discussed the Administrator . A copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
09/30/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210930110757

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: 40DATE:
10/21/2021
UNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:TIME COMPLETED:
01:20 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Residents don't have a call button
INVESTIGATION FINDINGS:
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On 10/21/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannouced visit to deliver the findings. LPA Han met with , and explaned the purpose of the visit. LPA was properly screened by the receptionist at the main entrance.

Regarding the allegation of- residents don't have a call button, the Reporting Party is alleging that there is no call buttin in Resident #2 (R2)'s room. The Lead Staff provided a tour of R2's room and LPA Han observed a call button in the room. According to R2, he/she did not notice that there was call button in the room as he/she was totally independent with all of the Activities of Daily Living (ADLs). However, due to the recent change of condition, R2 is still able to perform most of the ADLs but is requring some assistance with some of the tasks and according to R2, staff is very helpful.

Based on interviews and observation, the allegation is determined unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed with the Administrator. A copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021
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 3