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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600377
Report Date: 10/27/2020
Date Signed: 10/28/2020 02:37:30 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MERCED GIRARD RESIDENTIAL CARE FACILITYFACILITY NUMBER:
385600377
ADMINISTRATOR:WU, JAMES O.DFACILITY TYPE:
740
ADDRESS:129 GIRARD STREETTELEPHONE:
(415) 467-8900
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:42CENSUS: 39DATE:
10/27/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael LeeTIME COMPLETED:
03:30 PM
NARRATIVE
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On 10/27/20, Licensing Program Analyst (LPA) Mohamed Filouane, conducted a case management inspection alongside the complaint investigation, # 14-AS-20200302135404. Because of safety concerns and social distancing due to COVID19, LPA was not physically present in the facility. LPA spoke over the phone with Administrator Michael Lee and stated the purpose of the call.

During the Department's investigation, documentation collected indicated that the resident needed daily insulin injections. The Administrator stated that the facility has a Licensed Vocational Nurse (LVN) on staff who is available to provide injections. The collected documentation also shows that the facility did not have records of the resident's care plan. The Department interviews also indicate that the facility does not accept residents who cannot self administer their medication.

In addition, the Department's investigation found that a facility staff member observed the resident was lying down on the sofa at approximately 4PM and was believed to have fallen asleep; the same staff member checked on the resident about one hour later before dinner. The staff member found the resident unresponsive. The staff member, instead of calling 911 or the LVN, moved the resident to his room on a wheelchair and belted him in as to not fall over. Then the staff member called 911. The investigation also reveals that the staff member is aware that unresponsive residents are not to be moved before being cleared by emergency personnel. The staff member stated that they had made the decision to move the deceased resident away from the other 30-40 residents who were in the middle of dinner service.

Based on the Department's record review and interviews, which were conducted along with a file review, the preponderance of evidence has been met. California Code of Regulations (Title 22, Division 6, Chapter 8) are being cited on the attached LIC 9099D.

Exit interview conducted with the Licensee through video call. The Licensee will receive this LIC9099 report through email to sign. The Licensee will then email the signed version back to the LPA.

Exit interview conducted with Administrator Michael Lee.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 GIRARD RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600377
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/27/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/27/2020
Section Cited

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Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs.
Type A
11/27/2020
Section Cited

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Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental 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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/27/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2020
LIC809 (FAS) - (06/04)
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