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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600399
Report Date: 10/21/2021
Date Signed: 10/21/2021 01:18:53 PM

Document Has Been Signed on 10/21/2021 01:18 PM - It Cannot Be Edited

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:SAN FRANCISCO RCFEFACILITY NUMBER:
385600399
ADMINISTRATOR:ADELA MORALESFACILITY TYPE:
740
ADDRESS:887 POTRERO AVENUETELEPHONE:
(628) 206-6436
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 59CENSUS: DATE:
10/21/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Administrator, Adela MoralesTIME COMPLETED:
01:30 PM
NARRATIVE
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On 10/21/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced inspection and met with the Administrator, Adela Morales. LPA explained the purpose of the visit and delivered this finding.

During the course of the investigation of Complaint Control Number 14-AS-20210930110757, LPA Han observed Resident #1 (R1)'s Appraisal/Needs and Service Plan does not indicate R1's recent accident and hospitalization. The facility acknowledged that R1's Appraisal/Needs and Service Plan was not updated after the recent change of condition.

Based on records review, and interviews, the preponderance of evidence has been met. Deficiency was cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

This report was discussed with administrator. A copy of this report and licensee’s Appeal Rights forms given to administrator. Appeals must be directed to Licensing Regional Manager.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2021
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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Document Has Been Signed on 10/21/2021 01:18 PM - It Cannot Be Edited


Created By: Murial Han On 10/21/2021 at 12:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAN FRANCISCO RCFE
FACILITY NUMBER: 385600399

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2021
Section Cited
CCR
87506(a)

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RESIDENT RECORDS
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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The Administrator or the designee to update R1's Appraisal/Needs and Service Plan and submit a copy to the Regional Office. The Administrator or the designee will review the regulation, in-service staff and
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Based on records review and interview, the Administrator did not ensure Resident 1's (R1) appraisal and service plan reflect the current health status and needs as it does not reflect R1's recent change of condition which poses an potential Health and Safety risk to persons in care.
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submit a copy of the lesson plan and the sign-in sheet to Licensing by 11/4/2021.

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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 Montes
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2021


LIC809 (FAS) - (06/04)
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