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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600417
Report Date: 02/02/2024
Date Signed: 02/02/2024 03:18:09 PM


Document Has Been Signed on 02/02/2024 03:18 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:QUALITY CARE HOMES, LLC 2FACILITY NUMBER:
385600417
ADMINISTRATOR:FAROL, FERNAND & VERANO, MFACILITY TYPE:
740
ADDRESS:757 - 44TH AVENUETELEPHONE:
(415) 747-2074
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:6CENSUS: 5DATE:
02/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fernando Farol, AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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On February 2, 2024, Licensing Program Analysts(LPAs) John Calandra and Grace Donato, arrived at the facility at 10:00 AM to conduct an unannounced Annual 1-year required inspection. LPAs Calandra and Donato met with Jerry Caspillan, Caretaker. Administrator/Licensee, Fernand Farol joined the visit later.

LPA Calandra toured the physical plant. This is a 1-story building that consists of 5 rooms and 2 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and were checked while the LPAs were at the facility. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid kit was observed to be complete.

All knives and sharp objects were observed to be locked and in-accessible to persons in care.

All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

Administrator, Fernand Farol does not currently have control of property. Administrator currently leases property from his parents but did not have a sublease agreement or the current lease agreement available for LPAs to review.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: QUALITY CARE HOMES, LLC 2
FACILITY NUMBER: 385600417
VISIT DATE: 02/02/2024
NARRATIVE
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5 Resident files and 4 staff files were reviewed. All were observed to be complete.

Deficiencies are cited under Health and Safety Code,cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

The report was reviewed at the facility with Administrator, Fernand Farol and a copy along with Appeal rights were left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/02/2024 03:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: QUALITY CARE HOMES, LLC 2
FACILITY NUMBER: 385600417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.15(a)(2)
HSC1569.15(a)(2) License application, information required, change of information, penalties:

Evidence satisfactory to the department that the applicant is of reputable and responsible character. The evidence shall include, but not be limited to, a criminal record clearance pursuant to Section 1569.17, employment history, and character references. If the applicant is a firm, association, organization, partnership, business trust, corporation, or company, like evidence shall be submitted as to the individuals or entities holding a beneficial ownership interest of 10 percent or more, and the person who has operational control of the residential care facility for the elderly for which the application for issuance of license or special permit is made.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview with landlord and Licensee/Administrator, the licensee did not comply with the section cited above in 1 out of 1 lease agreeements in which the Licensee has not notified their landlord that they are subleasing from the tenant, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2024
Plan of Correction
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Licensee/Administrator to submit plan of correction, updated sublease agreement, and lease agreement to the Department by the POC due date.

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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2024
LIC809 (FAS) - (06/04)
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