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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600418
Report Date: 09/08/2021
Date Signed: 09/08/2021 11:08:26 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
08/30/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210830111743
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
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensee, Fernand FarolTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not refund responsible party
INVESTIGATION FINDINGS:
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On 9/8/2021, Licensing Program Analyst, (LPA) Han conducted 10-day complaint inspection. LPA met with the Licensee, Fernand Farol and explained the purpose of the visit.

Regarding to Licensee did not refund the Responsible Party, the Reporting Party explained that the facility failed to refund the full payment after Resident #1 was discharged from the facility. R1 was discharged on July 2, 2021 and the Reporting Party paid up to July 25, 2021. As of September 3, 2021, the Reporting Party received partial payment. In addition, the Reporting Party stated that the facility was made aware of the discharge at least a week prior to the day of discharge.

During today's visit, LPA interviewed the Licensee who confirmed that the facility has yet refund the remaining balance of $1000 to the Reporting Party.

Based on LPA interview, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20210830111743
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: 09/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/15/2021
Section Cited
CCR
87507(g)(5)(D)(1)
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ADMSISSION AGREEMENT
(g) Admission agreements shall specify the following:(5)Refund conditions.(D)The refund of prepaid monthly fees..1. If the resident provides notice five days...refunded at the time the resident leaves the facility and the unit is vacated.

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The Licensee will review the regulation and refund the remaining balance by 09/15/2021.
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This requirement was not met as evidence by Resident #1 was discharged on 7/2/2021 and as of 9/3/2021, the Responsible Party only received partial of the refund that he/she paid up to 7/25/2021.This posed a potential health, safety or personal rights risk to client.
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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
LIC9099 (FAS) - (06/04)
Page: 2 of 2