385600114-2-16-2021-14-AS-KHOS-BYJQAQ-20210224110015

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600114
Report Date: 02/16/2021
Date Signed: 02/16/2021 05:08:03 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
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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Reporting requirements - Individuals having access and contact with residents who tested positive with COVID 19 and licensee failed to report to CCL.

INVESTIGATION FINDINGS:

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On 2/16/21, at 5:00 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 reporting requirements, LPA Filouane conducted an investigation into the test date of the positive COVID-19 case, conducted interviews with facility staff and staff from the San Francisco Department of Public Health, and confirmed that the Community Care Licensing Division had, indeed, received a report from the facility.

Staff stated during interviews that the individual who tested positive for COVID-19 was asymptomatic before the testing. Staff also stated that the testing was routine. When questioned about the day the facility received the positive test results of the individual, staff stated they had made sure all of the facility residents were in their respective rooms before transferring the positive individual out of the facility for isolation at another location.

Unsubstantiated

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
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	Although the allegation 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. Exit interview conducted with the Administrator over the phone. The Licensee will receive this LIC9099 report through email to sign. The Licensee 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)

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