385600359-6-2-2021-14-AS-JMOS-C47LJ3-20210621084715

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600359
Report Date: 06/02/2021
Date Signed: 06/02/2021 02:47:47 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
05/17/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210517151546

FACILITY NAME:	CARLISLE, THE		FACILITY NUMBER:	385600359
ADMINISTRATOR:	FOX, ALAN		FACILITY TYPE:	740
ADDRESS:	1450 POST ST		TELEPHONE:	(415) 929-0200
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	130	CENSUS: 67	DATE:	06/02/2021
		UNANNOUNCED	TIME BEGAN:	02:20 PM
MET WITH:	Exective Director, Alan Fox		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility did not provide appropriate PPE for staff member

INVESTIGATION FINDINGS:

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On 6/2/21, Licensing Program Analysts (LPA) Murial Han conducted a follow-up complaint inspection with the Executive Director, Alan Fox. LPA explained the purpose of the visit and then delivered the findings.

Regarding facility did not provide appropriate PPE for staff members. LPA interviewed the Executive Director, the Resident Care Director, and the care team members who were assigned to the suspected and/or positive COVID-19 residents that included the Wellness Nurses, Medication Care Managers, and Care Managers (Caregivers).

The Executive Director and the Resident Care Director reported that no one has reported that they did not have the proper PPE Supplies including but not limiting N95 masks while caring for suspected and/or positive COVID-19 residents. LPA Han reviewed the facility inventory record which validated that the facility had enough PPE supplies during their COVIC-19 outbreak.

According to the Reporting Party, the Care Managers were assigned N95 masks individually, however, the Care Team Members reported that the N95 masks were kept in the Medication Room(s) which they have access to at anytime; they would grabbed the amount that they needed and logged it on a log.

Continued on 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

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-20210517151546

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: CARLISLE, THE	FACILITY NUMBER: 385600359
	VISIT DATE: 06/02/2021

NARRATIVE

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The Wellness Nurses and the Medication Care Managers validated that the N95 masks were kept in the Medication Room(s) and they have the key to open it. In addition, they reported that the facility has always been equipped with N95 masks as well as the other PPE supplies. They also reported that no one has expressed to them of not having the proper PPE supplies while caring for suspected and/or positive COVID-19 residents. In addition, they explained that when the Care Managers (Caregivers) arrived for their shift, they gathered their radio, their pager and obtained the number of N95 masks that they needed for their assignment for that day and then they logged the amount that they took.

During the interviews with the Care Managers, they also concurred with the Resident Care Director, the Wellness Nurses and the Medication Care Managers that N95 masks were kept in the Medication Room(s) and they grabbed the amount that they needed to care for the suspected and/or the positive COVID-19 residents and they logged it.

Furthermore, the staff members reported that before they start caring for their assigned residents, they would get a report from the previous shift so they knew their resident's health status and be prepared with the amount of N95 masks that they would need for that shift. They also reported that the rest of the PPE supplies such as gowns, gloves, etc. were set-up in an isolation kit with signs outside of the residents who were on quarantine which was another reminder for them to have all the appropriate PPEs prior to entering the room. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2021

LIC9099 (FAS) - (06/04)

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