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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600399
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:59:41 PM

Unfounded


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
06/30/2021 and conducted by Evaluator Mohamed Filouane
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210630093333
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: 40DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Adela MoralesTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Facility staff threatened resident.
Facility staff spoke inappropriately to resident.
Facility staff retaliated against resident for filing a complaint.
INVESTIGATION FINDINGS:
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On 8/25/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. LPA Filouane met and spoke Administrator Adela Morales, explained the purpose of the visit, and then delivered the findings.

Concerning the allegation of staff threatening the resident in question, LPA Filouane interviewed the Administrator and facility staff members. The Administrator stated staff do not threaten the residents. There was no additional evidence submitted to the Communtiy Care Licensing Division (CLLD). The investigation revealed no witnesses were present during any of the times it was alleged that facility staff spoke inappropiately to the resident in question. After review, this allegation is unfounded.

Concerning the allegation of facility staff speaking inappropriately to a resident, LPA Filouane interviewed the Administrator and facility staff.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
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 2
Control Number 14-AS-20210630093333
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: SAN FRANCISCO RCFE
FACILITY NUMBER: 385600399
VISIT DATE: 08/25/2021
NARRATIVE
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There was no additional evidence submitted to CCLD. The investigation revealed no witnesses were present during any of the time(s) it was alleged that facility staff spoke inappropriately to the resident in question. After review, this allegation is unfounded.

Concerning the allegation of facility staff retaliating against the resident in question for filing a complaint, LPA Filouane interviewed the Administrator and facility staff. The incident reported to LPA Han and verified with the Administrator revolved around the resident in question and a staff member raising their voices at each other. According to Title 22 regulations, that alone is not a violation. After review, this allegation is unfounded.

This agency has investigated the complaint. 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 the Administrator. A copy of this signed report will be emailed to the Administrator.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Mohamed Filouane
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2