385600418-9-8-2021-14-AS-KHOS-C7AKWU-20210928081630

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600418
Report Date: 09/08/2021
Date Signed: 09/08/2021 11:18:26 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
07/23/2020 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200723113845

FACILITY NAME:	QUALITY CARE HOMES, LLC 3		FACILITY NUMBER:	385600418
ADMINISTRATOR:	CESAR ARES		FACILITY TYPE:	740
ADDRESS:	2277 - 33RD AVENUE		TELEPHONE:	(415) 661-3477
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	12	CENSUS:	DATE:	09/08/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Licensee, Fernand Farol		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-- Facility staff not providing the residents medications as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 9/8/2021, Licensing Program Analyst (LPA) Han met with the Licensee, Fernand Farol to deliver the findings regarding the above allegation.

According to medical records, Resident 1 (R1) was hospitalized on July 16, 2020 and was discharged on July 18, 2020. On July 22, 2020, a medication change order was faxed over to co-administrator for the medications AMOXICILLIN/CLAVULANATE, FOSFOMYCIN, and NITROFURANTOIN.

According to R1’s most current Physician’s Report dated November 8, 2019, R1 needed assistance administering own prescription medications.

CONTINUE ON NEXT PAGE...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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-20200723113845

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: 09/08/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

According to staff interviews, administrator and Staff 1 (S1) stated that the medications were administered as prescribed and it was documented in a medication log or notebook. Medications were counted, and no discrepancies were found according to administrator. However, the facility’s medication administration log or notebook for R1 was unavailable to review.

Based on staff interviews and record reviews the allegation was deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or was valid, there was not a preponderance of evidence to prove that the alleged violation occurred.

Report was reviewed and discussed with the Licensee, Fernand Farol at the end of visit. A copy is provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 2