380504039-3-25-2021-14-AS-KHOS-BZLM3D-20210330091457

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380504039
Report Date: 03/25/2021
Date Signed: 03/25/2021 02:59:33 PM

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
03/17/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210317155413

FACILITY NAME:	LADY OF PERPETUAL HELP RFE #1		FACILITY NUMBER:	380504039
ADMINISTRATOR:	GREPO, CEASAR		FACILITY TYPE:	740
ADDRESS:	476 FAIR OAKS STREET		TELEPHONE:	(415) 648-9533
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	15	CENSUS: 11	DATE:	03/25/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Ceasar Grepo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility is locking gate, preventing access and egress

INVESTIGATION FINDINGS:

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On 3/25/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a 10-day complaint inspection visit with Licensee Ceasar Grepo, over the phone. Due to COVID-19 and health and safety concerns, LPA was not present in the facility. LPA informed the Licensee of the allegation, explained the purpose of the phone call, and then delivered the findings of the investigation in one visit.

Concerning the allegation of the facility locking the gate, LPA Filouane investigated and interviewed the Licensee. LPA verified with the Licensee during an interview why the facility's entrance gate has a padlock. The Licensee did not deny the allegation and confirmed that the entrance gate does, indeed, have a padlock preventing access into and out of the facility. During the interview, the Licensee stated the padlock was used as security to keep non-essential workers from entering the facility due to COVID-19 concerns. LPA explained to the Licensee that locking the residents on facility premises by day or night is a violation of their personal rights under Title 22 regulations.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

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-20210317155413

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: LADY OF PERPETUAL HELP RFE #1	FACILITY NUMBER: 380504039
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/25/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/25/2021 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.	1 2 3 4 5 6 7	The Licensee shall remove the padlock on the facility's entrance gate. The Licensee shall submit a picture of the facility's entrance gate without the padlock to CCLD.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: the Licensee failed to allow access for resident to leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20210317155413

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: LADY OF PERPETUAL HELP RFE #1	FACILITY NUMBER: 380504039
	VISIT DATE: 03/25/2021

NARRATIVE

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Based on LPA’s observations, record review, and interview, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 8) is being cited on the attached LIC 9099D.

Exit interview conducted with the Licensee over the phone. The Licensee will receive this LIC9099 report through email to sign and then will email or mail the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/25/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2021

LIC9099 (FAS) - (06/04)

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