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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600383
Report Date: 10/31/2024
Date Signed: 10/31/2024 02:19:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/22/2024 and conducted by Evaluator Dominic Tobola
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241022112243
FACILITY NAME:CARE AND CARE RESIDENCE IFACILITY NUMBER:
385600383
ADMINISTRATOR:JOSE NEVAREZFACILITY TYPE:
740
ADDRESS:940 HAIGHT STREETTELEPHONE:
(415) 829-2775
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:14CENSUS: 13DATE:
10/31/2024
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Michelle Perez, Lead CaregiverTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility has bed bugs
Staff inappropriately sprayed chemicals on a resident's bed
INVESTIGATION FINDINGS:
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On 10/31/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating complaint investigation and was greeted by Lead Caregiver Staff, Michelle Perez (S1). LPA toured the facility, interviewed staff and outside parties, photographed and made observations during the investigation.

Complaint alleges the facility has bed bugs. Upon interview with staff (S1 & S2), LPA was informed that staff had first been aware of bed bugs in resident's (R1) bedroom between 2-3 weeks prior to visit date. Based upon interview with Stepping Stone Day Program, Case Manager (I1), it was found that on 10/10/2024, I1 had conducted a facility visit and observed live bed bugs and bed bug carcasses on R1's bed and bedding. Additionally, on 10/17/2024, I1 observed bed bug carcasses under R1's bed and on 10/23/2024, R1 was observed to have a live bed bug on their clothing while attending day program.

During interview with staff, S1 indicated that they did not not notify facility manager when first observed, delaying the contact for exterminator services. The extermination services were first contacted with a copy of the signed agreement for services dated 10/22/2024. Additional documentation indicated that the first visit conducted by the exterminator was on 10/25/2024, multiple days after bed bugs were first observed in the facility. Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
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-20241022112243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CARE AND CARE RESIDENCE I
FACILITY NUMBER: 385600383
VISIT DATE: 10/31/2024
NARRATIVE
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Upon facility inspection LPA and S1 observed multiple bed bug carcasses in R1's bedroom #5. S1 stated that the bed bugs had not spread throughout the facility. However, LPA observed additional bed bug carcasses near R1's roommate's bed, as well as in the adjacent bedroom #6 and in bedroom #1 located at the furthest end of the hallway from R1's quarters. LPA found that the bed bugs had spread throughout the facility effecting multiple bedrooms (photos taken).

Complaint alleges staff inappropriately sprayed chemicals on a resident's bed. Upon interview with staff (S1), LPA was informed that bed bug chemical spray was applied around R1's bed and wall area. LPA was shown the chemical spray confirming that R1's living quarters had been exposed to chemicals (photos taken). In addition, upon interview with Stepping Stone Day Program Case Manager (I1), I1 indicated that during their visit to the facility, I1 had witnessed staff applying the chemical spray directly on R1's bed and bedding, effecting R1's furnishing, equipment and living accommodations.

Allegations, facility has bed bugs & staff inappropriately sprayed chemicals on a resident's bed are found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20241022112243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: CARE AND CARE RESIDENCE I
FACILITY NUMBER: 385600383
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/01/2024
Section Cited
CCR
87303(a)
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87468.1: Personal Rights of Residents in All Facilities - To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidence by: Based upon LPA observation and photos taken, the facility was observed to have bed bug carcasses in resident (R1) bedroom as well as multiple bedrooms throughout the facility. In addition, upon interviews with staff (S1 & S2) and outside parties (I1), bed bugs were observed as early as 10/10/2024 without acquiring extermination services until 10/22/2024.
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The facility has contacted appropriate extermination services as of 10/22/2024 and conducted their first service visit on 10/25/2024. The facility failed to initially respond to the bed bug infestation, however has not taken corrective measures. Deficiency cleared at time of visit.
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Lastly, interviews with I1 indicate that I1 observed both live and dead bed bugs in R1's bedroom and on R1's person on mulitple occasions from 10/10/2024 to 10/23/2024. This serves as an immediate health & safety risk to residents in care.
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In addition, Licensee is to provide documentaiton of each exterminator visit and status of bed bug infestation to CCLD until services habe been completed.
Type A
11/01/2024
Section Cited
CCR
87307(d)(2)
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87307: Personal Accommodations and Services - The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This was not met as evidence by: Based upon interviews with staff (S1) it was found that bed bug chemical spray was applied around resident R1's bed.
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The facility has replaced the mattresses for R1 and all residents in care. LPA observed new mattresses and clean bedding during visit. Although bed bug carcasses were still observed during visit, the facility has taken appropriate measures to treat bed bug infestation. Deficiency cleared at time of visit.
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 In addition, interview with outside party (I1) indicated that I1 witnessed staff spray the chemicals directly on R1's bed and bedding. This serves as an immediate health & safety risk to residents 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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3