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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600360
Report Date: 09/08/2023
Date Signed: 09/08/2023 11:04:25 AM

Substantiated


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
08/29/2023 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 14-AS-20230829093022
FACILITY NAME:VICTORIAN MANORFACILITY NUMBER:
385600360
ADMINISTRATOR:ANA PACHECOFACILITY TYPE:
740
ADDRESS:1444 MCALLISTER STREETTELEPHONE:
(415) 921-7550
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:124CENSUS: 84DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ana Pacheco, AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Resident is being illegally evicted.
INVESTIGATION FINDINGS:
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On 09/08/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator, Ana Pacheco and explained the purpose of today's visit.

Regarding the allegation of resident (R1) being illegally evicted. Reporting party (RP) received a letter of immediate eviction from the facility.

LPA confirmed that the facility sent out a letter stating immediate eviction of R1. LPA also interviewed Administrator and and a copy was provided. Based on record reviews, the reassessment of R1 determined that the facility is not able to provide the level of care that R1 needs. While an eviction is warranted, the facility gave an immediate eviction notice, per Title 22, a 30-day notice to R1 is required.

Based on interviews and record reviews the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator. A copy of this report and the Appeal Rights are provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
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 3
Control Number 14-AS-20230829093022
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VICTORIAN MANOR
FACILITY NUMBER: 385600360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
CCR
87224(a)
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87224(a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph (5). This requirement was not met as evidenced by :
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Licensee shall amend eviction notice that provides 30 days from day letter is sent. Develop a plan and to ensure eviction procedures are followed in section 87224. Licensee to submit POC to Licensing by POC due date
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Based on interviews and record reviews the facility gave an immediate eviction notice, per Title 22, a 30-day notice to R1 is required which poses an immediate health, safety, or personal rights risk to persons in care.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
08/29/2023 and conducted by Evaluator Grace Donato
COMPLAINT CONTROL NUMBER: 14-AS-20230829093022

FACILITY NAME:VICTORIAN MANORFACILITY NUMBER:
385600360
ADMINISTRATOR:ANA PACHECOFACILITY TYPE:
740
ADDRESS:1444 MCALLISTER STREETTELEPHONE:
(415) 921-7550
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:124CENSUS: 84DATE:
09/08/2023
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Ana Pacheco, AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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9
Facility is retaliating against resident for making complaints.
INVESTIGATION FINDINGS:
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On 09/08/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegation. LPA met with Administrator, Ana Pacheco and explained the purpose of today's visit.

Regarding the allegation of facility is retaliating against resident for making complaints. RP stated that resident (R1) is being evicted due to filing complaints against the facility.

Based on interview with the Administrator, it was stated that there was no retaliation for R1, the reason for eviction is because the facility is not able to provide the needs of the resident based on a reassessment that was conducted on 7/26/23. The facility is an assisted living facility and is not able to provide proper care for residents who needs to have mental illness addressed.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report was discussed with Administrator and a copy of this report is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3