385600114-2-17-2021-14-AS-KHOS-BYJQAP-20210224110015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600114
Report Date: 02/16/2021
Date Signed: 02/17/2021 10:17:11 AM

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
01/14/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210114152727

FACILITY NAME:	MERCED RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	385600114
ADMINISTRATOR:	WU, JAMES D.		FACILITY TYPE:	740
ADDRESS:	259 BROAD STREET		TELEPHONE:	(415) 585-6112
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	14	CENSUS: 14	DATE:	02/16/2021
		UNANNOUNCED	TIME BEGAN:	04:30 PM
MET WITH:	Luong Ly (Jack)		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Inimical conduct of licensee for not following COVID-19 guidelines

INVESTIGATION FINDINGS:

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On 2/16/21, at 4:30 PM, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. Because of COVID-19 and social distancing measures, LPA Filouane called and spoke to Administrator Loung Ly over the phone, explained the purpose of the call, and delivered the findings.

In regard to the allegation concerning the Licensee's inimical conduct of not following COVID-19 safety guidelines, LPA Filouane conducted an investigation, interviewed staff members, staff of the San Francisco Department of Public Health (SFDPH), and reviewed the facility's files.

During interviews with LPA Filouane, facility staff and SFDPH staff stated that the Licensee and his family flew to another state against the COVID-19 travel restriction advisories and SFDPH's advisory. When the Licensee and the family returned from the trip, the family quarantined within the facilityg. On 1/7/21, an individual from the Licensee's family tested positive for COVID-19, asymptomatic. The individual was then transferred out of the facility on 1/7/21 to isolate at another location. Interviews with SFDPH revealed the facility had potential for a large COVID-19 infection outbreak with the one positive case on 1/7/21.

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: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

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-20210114152727

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: MERCED RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 385600114
	VISIT DATE: 02/16/2021

NARRATIVE

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The inimical conduct of the Licensee is the danger the facility residents faced when the Licensee's family member, who had been quarantining in the facility after travelling, tested positive for COVID-19. The facility's population is the elderly, who are at highest risk to the disease, according to the Centers for Disease Control and Prevention. Against advisory of SFDPH and CDC, the Licensee's inimical conduct resulted in deciding to travel out of state, return, and quarantine in the facility, placing the residents at risk with the positive COVID-19 case.

Based on LPA’s observations, record review, and interviews, 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 Administrator over the phone. The Administrator will receive this LIC9099 report through email to sign. The Administrator will then email 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: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20210114152727

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: MERCED RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 385600114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/17/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Personal Rights (a) (2) esidents in all residential care facilities for the elderly shall have all of the following personal rights: to be accorded safe, healthful and comfortable accommodations...	1 2 3 4 5 6 7	The Licensee shall make decisions to adhere to the Personal Rights of the residents in the facility and to accord safe and healthful accomodations.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: the Licensee travelled out of state against CDC advisory and local health department advisory and upon return, quarantined in the facility where elderly residents resided.	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: 02/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2021

LIC9099 (FAS) - (06/04)

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