385600367-11-30-2022-14-AS-CSMH-CM5W4G-20221215155727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600367
Report Date: 11/30/2022
Date Signed: 11/30/2022 10:39:55 AM

Unsubstantiated

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
08/19/2020 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200819090048

FACILITY NAME:	MARIAN'S CARE HOME I		FACILITY NUMBER:	385600367
ADMINISTRATOR:	CUA, MARIAN TORRES		FACILITY TYPE:	740
ADDRESS:	1450 - 24TH AVENUE		TELEPHONE:	(415) 269-1500
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	6	CENSUS: 6	DATE:	11/30/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Marian Cua		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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- Staff did not administer residents medication
- Staff did not provide resident with food
- Staff did not meet residents needs

INVESTIGATION FINDINGS:

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On 11/30/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit on behalf of LPA Jaime Vado to deliver the finding. LPA Han met with the Administrator, Marian Cua and explained the purpose of the visit.

Investigation Summary
This investigation was opened and started by LPA Raygoza. The complaint was reassigned to LPA Vado. LPA Vado met with LPA Raygoza and discussed the allegations and her findings. She says that she has already marked the allegations as unsubstantiated based on the interviews conducted and documents received from the facility. She says that per the documentation received and staff interview it appears that the facility did administer medications, provide food to the resident, and tried to meet the needs of the resident.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

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-20200819090048

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: MARIAN'S CARE HOME I	FACILITY NUMBER: 385600367
	VISIT DATE: 11/30/2022

NARRATIVE

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LPA reviewed the documents received from the facility and included case notes showing the notes by staff showing that they did attempt to provide services to the resident including the medications and feeding. The logs show the actions the facility took each time they assisted the resident. Records show that the medication list was provided to the daughter, the complainant, directly to show what medications the resident is receiving and the quantity. A medication profile, which acts as a medication prescription list as well as resident diagnosis. The list appears to be from the PCP of the resident and matches the meds administered on the facility's case notes. The case notes show that they provided food to the resident and that the resident also requested food. In regards to the residents needs being met, the case notes show all the services provided to the resident such as assisting to the commode, feeding, bathing, repositioning, exercising, etc. The resident was also received home health services by American Care Quest to provide Oxycodone and Fentanyl patches as some of the controlled medications. They provided help in regards to the resident's cancer.
LPA Vado attempted to reach the complainant but did not receive contact back. Per the documentation provided from previous LPA Raygoza the complainant did not contact her as well. According to LPA Raygoza report dated 08/27/2020, the resident only resided at the facility for two weeks and was removed by the daughter at her own will. Facility did not charge the responsible party for the two weeks they provided care to the resident as an act of good faith.
Due to the provided documents LPA Vado concurs with the findings of LPA Raygoza in delivering the findings as UNSUBSTANTIATED.
This report is reviewed and discussed with the administrator. A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2022

LIC9099 (FAS) - (06/04)

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