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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600399
Report Date: 10/25/2023
Date Signed: 10/25/2023 01:38:18 PM

Substantiated


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
08/17/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230817121522
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: 45DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Interim AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility did not provide computer to resident
INVESTIGATION FINDINGS:
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On October 25, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the investigation findings. LPA met with Interim Administrator, Charisse Ann Li and explained the purpose of the visit.

Regarding to allegation of - facility did not provide computer to resident.

As part of the investigation, LPA interviewed resident - in - question (R1) and interim administrator.

According to R1, there is no computer access for residents at the facility which made it impossible for R1 and other residents to search the internet and other activities.

The interim administrator acknowledged that there is no electronic device for residents and it is vital for residents to have access to an electronic device. Therefore, the facility will be working on obtaining it for the residents.

Based on interviews and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiency is cited on the LIC 9099D under Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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 5
Control Number 14-AS-20230817121522
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/01/2023
Section Cited
HSC
1569.319(a)
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ยง1569.319..(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer,.. that can support real-time interactive applications,..and is dedicated for resident use.
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The administrator/licensee will develop a plan to ensure compliance and will submit a copy of the plan to CCL by 11/1/2023.
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This requirement is not met as evidenced by facility did not have internal access device such as a computer for residents to access which poses a potential health risk to residents in care.
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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.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/17/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230817121522

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: DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Interim AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
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Facility did not ensure resident's personal belongings are secured
Staff behavior towards resident was unacceptable
INVESTIGATION FINDINGS:
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On October 25, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the investigation findings. LPA met with interim administrator, Charisse Ann Li and explained the purpose of the visit.

Regarding to allegation of - facility did not ensure resident's personal belongings are secured, the reporting party stated facility failed to secure resident - in - question (R1)'s personal belongings.

As part of the investigation, LPA interviewed R1, interim administrator and other residents.

According to R1, his/her personal belongings were secured in the room, however, 2 hats were missing from the washer during laundry. R1 stated that he/she did not report this to facility staff and R1 was not able to provide additional details of the missing hats.

According to interim administrator, the laundry is locked at all times and only facility staff has the key to open the door. The interim administrator also stated that a long time ago, some residents reported clothes were missing from the laundry room but not recently.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
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 5
Control Number 14-AS-20230817121522
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: 10/25/2023
NARRATIVE
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LPA interviewed 3 other residents who did their own laundry and all of them stated that they have not had any of their clothes missing from the laundry room.

After the investigation, this allegation is deemed to be unsubstantiated as R1 did not report to facility staff when the hats were missing, and R1 was not able to provide additional details of the missing hats.

Regarding to allegation of- Staff behavior towards resident was unacceptable, the reporting party reported resident- in - question (R1) experienced unacceptable behavior from staff members.

As part of the investigation, LPA interviewed R1 and interim administrator.

According to R1, he/she did not like the way he/she was being talked to by staff #1 (S1). R1 denied being mistreated by S1 but did not like the tone of voice such as when R1 did not want to take his/her medication, and felt he/she was being questioned by S1. However, R1 was not able to provide additional details and R1 stated that it was not reported to any team leaders and supervisors.

LPA interviewed interim administrator who stated that S1 is being monitored on work related tasks but no one has expressed concerned about S1's tone of voice while talking to residents.

LPA interviewed a team leader who reported that residents have not reported any concerns of any staff members being rude to them.

LPA interviewed 3 residents and they all reported that facility staff members are caring, doing their best to care for them and they are friendly.

After the investigation, this allegation is deemed to be unsubstantiated as R1 stated that he/she was not mistreated by S1 and interim administrator will speak to S1 regarding to the tone of voice while speaking to residents.

Although the above investigations 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 allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with interim administrator; a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
08/17/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230817121522

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: DATE:
10/25/2023
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Interim AdministratorTIME COMPLETED:
01:50 PM
ALLEGATION(S):
1
2
3
4
5
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9
Facility did not provide a healthful, and comfortable accommodations to resident
INVESTIGATION FINDINGS:
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On October 25, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the investigation findings. LPA met with Charisse Ann Li and explained the purpose of the visit.

Regarding to allegation of- facility did not provide a healthful, and comfortable accommodations to resident, the reporting party stated that the allegation was related to secondhand smoke at the facility.

As part of the investigation, LPA interviewed resident - in - question (R1) who clarified that R1 was not inhaling secondhand smoke rather R1 used to be a smoker and when R1 walked by the designated smoking areas and/or smelled smoke on other residents, it reminded R1 that he/she used to smoke but R1 was very firmed that he/she would never smoke again. R1 also stated that he/she did not feel the facility was unhealthful and/or uncomfortable for him/her as all the smokers only smoked in the designated smoking area(s).

After the investigation, this allegation is deemed to be unfounded.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report was discussed and a copy of this report is provided.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5