385600399-7-21-2023-14-AS-CSMH-CUJN6L-20230809101118

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600399
Report Date: 07/21/2023
Date Signed: 07/21/2023 12:09:11 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
07/11/2023 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20230711084418

FACILITY NAME:	SAN FRANCISCO RCFE		FACILITY NUMBER:	385600399
ADMINISTRATOR:	ADELA MORALES		FACILITY TYPE:	740
ADDRESS:	887 POTRERO AVENUE		TELEPHONE:	(628) 206-6436
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	59	CENSUS: 41	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Adela Morales		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Facility is retaining residents with higher level of care needs.

INVESTIGATION FINDINGS:

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On July 21, 2023, Licensing Program Analysts (LPAs) Grace Donato and Komal Charitra conducted an unannounced 10-day complaint visit. LPAs met with Team Leader, Darren Page, and Program Director, Adela Morales joined shortly thereafter. LPAs explained the purpose of the visit.

Regarding the allegation that facility is retaining residents with higher level of care, according to the reporting party, the facility is retaining clients who require a higher-level of care and staff are not equipped to provide care for them. According to the reporting party, Resident 1 (R1) has breathing issues and needs oxygen, however facility can’t take anyone with oxygen, Resident 2 (R2) is obsessed with smoking and will wake residents up at night to ask for cigarettes, and Resident 3 (R3) has bad dementia and needs to be in a memory care facility.

During the investigation, LPAs reviewed resident files and interviewed the Program Director and Team Leader. Based on interviews conducted with the Program Director and Team Leader, R1 does not

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

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-20230711084418

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SAN FRANCISCO RCFE	FACILITY NUMBER: 385600399
	VISIT DATE: 07/21/2023

NARRATIVE

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require oxygen. Based on R1’s physician report dated 7/13/2023, it was documented that R1 has resolved aspiration pneumonia and does not require oxygen.

LPAs reviewed R2’s file and the facility house rules regarding smoking. Based on the facility house rules and interviews conducted, the facility does not allow residents to smoke cigarettes inside the facility, however residents are allowed to smoke cigarettes in the designated smoking areas. In addition, based on the interviews conducted, residents are able to smoke when they like as the facility does not have a smoking schedule. Based on R2’s file, LPAs observed a written agreement between the facility and R2 indicating that R2 will receive a fixed amount of cigarettes per day by facility.

Furthermore, LPAs reviewed R3’s file. Based on R3’s file, R3 was admitted to the facility on January 2021. Upon admission, R3 did not have a diagnosis of dementia. The physician’s report documentation dated, April 2023 indicated R3 was diagnosed with dementia. According to the Program Director and Team Leader, the facility has been in contact with SFDPH Placement Team and R3’s case manager, however, has not been successful with finding R3 placement. In addition, according to the Program Director, R3 is currently at the San Francisco General Hospital due to R3’s progressive dementia and the social workers and case managers at the hospital are assisting with trying to find R3 placement.

Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation that the facility is retaining residents with higher level of care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Program Director, Adela Morales and a copy is provided.

SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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