380540408-8-24-2021-14-AS-KHOS-C6FJV6-20210901072238

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380540408
Report Date: 08/24/2021
Date Signed: 08/24/2021 12:33:54 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
08/16/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210816132046

FACILITY NAME:	JANET'S RESIDENTIAL FACILITY FOR THE ELDERLY		FACILITY NUMBER:	380540408
ADMINISTRATOR:	SPIRES, JANET		FACILITY TYPE:	740
ADDRESS:	2970 25TH AVENUE		TELEPHONE:	(415) 759-8137
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94132
CAPACITY:	8	CENSUS: 6	DATE:	08/24/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Administrator, Janet Spires		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff are not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/24/21, Licensing Program Analyst (LPA) Murial Han conducted a 10-day complaint inspection on-site visit and met with the Administrator, Janet Spires. LPA was properly screened at the entrance and LPA explained the purpose of the visit and reviewed the allegation.

Regarding to facility staff are not following COVID-19 guidelines, the complainant reported that the facility staff was not wearing their masks over their nose. During LPA's visit, LPA observed the caregivers were their masks on properly and the masks were covering their nose and mouth while they were providing care to the residents.

LPA interviewed the Administrator who denied the allegation and stated that the above allegation was never brought to her attention. In addition, the staff members have been trained by the Local Public Health on the proper way of wearing masks and returned demonstration of their knowledge.

In addition, LPA interviewed the caregivers who stated that they were not aware that anyone has concerns regarding to their face covering and that they were fully aware that masks should be covering their nose and mouth and it should not be on neck and/or chin at all times.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

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 2

Control Number 14-AS-20210816132046

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: JANET'S RESIDENTIAL FACILITY FOR THE ELDERLY	FACILITY NUMBER: 380540408
	VISIT DATE: 08/24/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Furthermore, LPA interviewed Resident #1 (R1) and Resident #2 (R2) regarding to the facility's practice on face covering and both residents validated that staff members wear masks over/covering their noses and mouths at all times.

Base on observation and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigation 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.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2