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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600377
Report Date: 10/27/2020
Date Signed: 10/28/2020 02:45:32 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
03/02/2020 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200302135404
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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael LeeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
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5
6
7
8
9
Questionable Death
Neglect/Lack of supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/27/20, Licensing Program Analyst (LPA) Mohamed Filouane called over the phone to conduct a follow-up investigation visit. Because of social distancing and COVID19 safety measures, LPA was not physically present in the facility. LPA explained to Administrator Michael Lee the purpose of the phone call and delivered the findings of the investigation.

During the investigation, the Department conducted interviews, reviewed and collected the client's medical and non-medical records.

Regarding the allegation concerning questionable death, the Department found no evidence that the resident died at the facility due to questionable circumstances. Records collected by the Department indicate that the resident passed away of natural causes. The evidence collected by the Department, to include autopsy, law enforcement report, patient care reports and medical records showed that the resident had a history of multiple, serious health issues and his death was due to natural causes.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20200302135404
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 GIRARD RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600377
VISIT DATE: 10/27/2020
NARRATIVE
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This agency has investigated the complaint alleging a questionable death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

The Department also found that the evidence obtained did not support that facility negligence contributed to the death of the resident. Facility staff reported nothing unusual or inappropriate prior to the resident’s death. Responding emergency personnel also failed to report any unusual circumstances. The autopsy report further revealed no evidence of anything unusual. The resident was in a respite care at the facility and had been there for only a couple of days.

This agency has investigated the complaint alleging a questionable death. We have found that the complaint was UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

Exit interview conducted with Administrator Michael Lee. This report was emailed to the Administrator for a signature. The Administrator will email this signed report back to the LPA.
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 licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
03/02/2020 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200302135404

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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Michael LeeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility has inadequate record keepnig for resident while in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 10/27/20, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit with the Administrator, Michael Lee, over the phone. Because of social distancing precautions and the COVID19 pandemic, LPA was not physically present in the facility. LPA explained the purpose of the visit and informed the Administrator of the allegation.

The complainant stated that the facility had denied access to the resident’s medical documentation; therefore, the complainant alleged the facility did not have complete records. The Administrator denied the allegation. He stated that the facility had collected all the medical notes and required documentation of the resident in question. The records, however, cannot be surrendered without going through channels to verify if the requestor is authorized to have such records. LPA Filouane verified that the facility had the corresponding records.
Unsubstantiated
Estimated Days of Completion:
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 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.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20200302135404
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 GIRARD RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600377
VISIT DATE: 10/27/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
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21
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23
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32
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Administrator Michael Lee. The Administrator will receive this LIC9099 report through email to sign. The Administrator will then email the signed version back to the LPA.
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 licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4