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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600418
Report Date: 06/28/2021
Date Signed: 06/28/2021 11:45:02 AM



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
05/03/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210503143234
FACILITY NAME:QUALITY CARE HOMES, LLC 3FACILITY NUMBER:
385600418
ADMINISTRATOR:CESAR ARESFACILITY TYPE:
740
ADDRESS:2277 - 33RD AVENUETELEPHONE:
(415) 661-3477
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:12CENSUS: 7DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, Fernand FarolTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff are not following COVID protocol
Facility staff is not providing proper Catheter care
INVESTIGATION FINDINGS:
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On 6/ 28/ 21, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint inspection to deliver the findings. LPA met with the Licensee, Fernand Farol and explained the purpose of the visit.

Regarding allegation of facility staff are not following COVID protocol, the reporting party stated that he/she was not screened upon arrival at the facility. During LPA's visit on 6/16/2021 at 1:35pm, LPA was properly screen at the upstairs entrance. However, LPA observed two visitors who entered from the downstairs entrance were not screened; the screening log was reviewed and verified that the visitors were screened. The facility has the required screening stations and those residents interviewed indicated that visitors are screened. Staff also indicated that this was an isolated oversight. Nevertheless, the complainant and LPA’s observations provide preponderance of evidence that staff have not always followed COVID protocols.

Based on observation and record review, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated.

This report is continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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 4
Control Number 14-AS-20210503143234
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: QUALITY CARE HOMES, LLC 3
FACILITY NUMBER: 385600418
VISIT DATE: 06/28/2021
NARRATIVE
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Regarding to the allegation of facility staff is not providing proper Catheter care, Resident 1 (R1), the Department's investigation found that a resident (R1) had been admitted with a catheter. A licensee is permitted to accept or retain a resident who requires the use of an indwelling catheter as long as the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. A licensee would be allowed to accept and/or retain a resident who do not meet this criteria upon receiving an exception from the Department. In this case, the resident's appraisal/needs and service plan stated that R1 has difficulty adjusting emotionally due to dementia, therefore, R1 was not mentally nor physically capable of caring for the catheter. Furthermore, the facility failed to obtain an exception for the resident's condition, and failed to developed an appropriate care plan. Based on this information, there is preponderance of evidence to demonstrate that the staff was not providing proper catheter care.

Based on interview and record review during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated.

This report was reviewed and discussed with the Licensee and a copy is provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20210503143234
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: QUALITY CARE HOMES, LLC 3
FACILITY NUMBER: 385600418
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2021
Section Cited
CCR
87623(a)(1)
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87623 Indwelling Urinary Catheter: (a)The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances:(1)If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. This requirement is not met as evidenced by:
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The Administrator will review Title 22 regulation section 87623 and educate staff members.
The Administrator will submit sign-in sheet(s) and the content of the education to CCLD San Bruno Regional Office by 7/12/2021.
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Based on record review and interview, the facility accepted and retained a resident with a catheter; (R1) was incapable to physically and mentally caring for all aspects of his/her condition, and the licensee failed to develop an appropriate care plan to include an exception under the corresponding regulation which poses an immediate health, safety, and personal rights to persons in care.
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Type B
07/12/2021
Section Cited
CCR
80072(a)(2)
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de, but are not limited to be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.
This requirement is not met as evidence by:
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The Administrator will educate staff on the importance of the COVID-19 screening process upon arrival.
The Administrator will conduct random checks to ensure this practice is being followed.
The Administrator will submit the in-service record(s) and the content of the education to CCLD San Bruno Regional Office by 7/12/2021.
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Based on observation and record review, the facility did not ensure visitors complete the COVID-19 screening process by the entrance upon arrival which poses a potential health, safety, and personal right risks to persons 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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 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
05/03/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210503143234

FACILITY NAME:QUALITY CARE HOMES, LLC 3FACILITY NUMBER:
385600418
ADMINISTRATOR:CESAR ARESFACILITY TYPE:
740
ADDRESS:2277 - 33RD AVENUETELEPHONE:
(415) 661-3477
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:12CENSUS: DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Licensee, FernandTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility staff handle resident aggressively
INVESTIGATION FINDINGS:
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On 6/ 28 / 21, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint inspection to deliver the findings. LPA met with the Licensee and explained the purpose of the visit.

Regarding to the allegation of facility staff handled resident aggressively, the reporting party stated that Staff 1 (S1) was so strong, fast and forceable while gilding Resident 1 (R1) towards the facility stairs, it could harmed R1. However, there is no additional information forthcoming from the complainant.

S1 is no longer employed by the facility, and could not be located to provide a response to the allegation. LPA interviewed S1's co-worker and the Licensee and both of then denied the allegation and reported that S1 provided good care to the residents and he was a good worker. Furthermore, LPA interviewed family members regarding to the care that their loved ones are receiving at the facility and they reported that the care is good and they are satisfied with facility and staff members.

Based staff and family interviews during the investigation, this allegation is unsubstantiated.

Although the allegation may have happened and/or valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the Administrator and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4