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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380504039
Report Date: 05/22/2023
Date Signed: 05/22/2023 11:39:52 AM

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
05/27/2022 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220527162849
FACILITY NAME:LADY OF PERPETUAL HELP RFE #1FACILITY NUMBER:
380504039
ADMINISTRATOR:GREPO, CEASARFACILITY TYPE:
740
ADDRESS:476 FAIR OAKS STREETTELEPHONE:
(415) 648-9533
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:15CENSUS: 10DATE:
05/22/2023
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Ceasar GrepoTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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- Staff mistreats the residents while in care
- Staff inappropriately elbowed a resident while in care
- Resident sustained injuries from multiple falls while in care
INVESTIGATION FINDINGS:
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Based on interviews with staff, clients and witnesses, these allegations are determined to be unsubstantiated.

Some residents participate in household chores if they choose to do so; none of the 5 clients that LPA interviewed reported that anyone is forced to do chores if they object.
The incident of a client being elbowed by a staff may have occurred over 2 years ago and information is not readily available.
It cannot be determined that injuries sustained by a client are attributed to negligence by staff.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2023
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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