385600418-9-8-2021-14-AS-KHOS-C8KN9V-20211108091632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600418
Report Date: 09/08/2021
Date Signed: 09/08/2021 12:08:06 PM

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
07/21/2020 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200721133634

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:	12:15 PM

ALLEGATION(S):

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-- Facility failed to follow proper reporting requirement.

-- Facility failed to issue proper refund.

INVESTIGATION FINDINGS:

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On 9/8/2021, on behalf of Licensing Program Analyst (LPA) Michael Garcia, LPA Murial Han met with the Licensee, Fernand Farol to deliver the findings regarding the above allegations.

-- Facility failed to follow proper reporting requirement.: According to staff interviews, Staff 1 (S1) stated that on June 13, 2020, Resident 1 (R1) passed away at the facility. Staff 2 (S2) informed the person responsible for R1, via telephone, to report about the death according to S1. However, no written report was submitted to the licensing agency and to the person responsible for R1 within 7 days of R1’s death as confirmed by co-administrator.

On July 30, 2020, LPA received R1’ Death Report via email which was dated on the same day – July 30, 2020.
CONTINUE ON NEXT PAGE...

Substantiated

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)

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Control Number 14-AS-20200721133634

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

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-- Facility failed to issue proper refund.: According to facility records, R1 passed away on June 13, 2020 per R1’s Death Report.

According to staff interviews, co-administrator stated that there was a misunderstanding if a refund was to be issued depending if a resident passed away under hospice care or not as stated in the facility’s Admission Agreement. Co-administrator confirmed that R1 was not under hospice care at the time of death and will issue proper refund.

On August 25, 2020, co-administrator stated that a partial refund was issued to the responsible person for R1 early that month and that an additional $600 will be refunded shortly.

The allegations were SUBSTANTIATED, meaning that the allegations were valid because the preponderance of the evidence standard have been met. The following deficiencies were cited under California Code of Regulations, Title 22 – refer to the LIC9099-D for more details. Appeal Rights given.

Report was reviewed and discussed with the Licensee 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)

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Control Number 14-AS-20200721133634

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 87211(a)(1)(A)	1 2 3 4 5 6 7	Reporting Requirements... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of... (A) Death of any resident...	1 2 3 4 5 6 7	On 07/30/21, co-administrator emailed R1's Death Report to LPA. In addition, administrator shall ensure to submit a written action plan describing how it will ensure that written reports are submitted in
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on staff interviews and record review, the licensee failed to submit a written report of R1' death to the licensing agency and to the person responsible for R1, which posed potential health and safety risk to residents in care.	8 9 10 11 12 13 14	accordance to Regulation Section 87211(a)(1)(A) and submit it to the licensing office by the POC due date, 9/15/2021
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	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2021

LIC9099 (FAS) - (06/04)

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