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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600418
Report Date: 09/08/2021
Date Signed: 09/08/2021 05:14:26 PM

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: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:
09/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Fernand FarolTIME COMPLETED:
12:00 PM
NARRATIVE
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On 9/8/2021, Licensing Program Analyst (LPA) Murial Han conducted a visit on behalf of LPA Michael Garcia to deliver the finding from the Case Management unannounced complaint inspection that was conducted by LPA Garcia on 7/14/2021.


During the investigation for complaint #14-AS-20200723113845, medications for Resident 1 (R1) were administered as prescribed and documented in a medication log or notebook according to two staff members. However, the medication log or notebook for Resident 1 (R1) was unavailable for review.

Deficiency observed during inspection (see LIC809-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Exit interview conducted and Appeal Rights provided.

Report was reviewed and discussed with the Licensee at the end of visit. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited

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87506 Resident Records. (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours.
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This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee failed to ensure that medication administration record for R1 was available for the licensing agency to inspect during normal business hours which posed potential health 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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2021
LIC809 (FAS) - (06/04)
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