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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600418
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:20:11 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 3FACILITY NUMBER:
385600418
ADMINISTRATOR:CESAR ARESFACILITY TYPE:
740
ADDRESS:2277 - 33RD AVENUETELEPHONE:
(415) 661-3477
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:12CENSUS: 0DATE:
11/02/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver, Rosalinda SubidaTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Facility failed to issue proper refund.
INVESTIGATION FINDINGS:
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On 11/2/2021, on behalf of Licensing Program Analyst (LPA) Michael Garcia, LPA Murial Han met with the caregiver, Rosalinda Subida to deliver the findings regarding the above allegations for Quality Care Homes, LLC 3.

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 caregiver, Rosalinda Subida at the end of visit. A copy is provided.
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: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
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-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: 11/02/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2021
Section Cited
CCR
1569.652(c)
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Termination of admission agreement upon death of resident; ... (c) A refund of any fees paid in advance... shall be issued to the ... resident’s estate, within 15 days ...
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Co-administrator issued a partial refund to the person responsible to R1. Co-administrator shall ensure to submit proof of proper refund was issued to the person responsible for R1 and submit a copy of it to the licensing office by the POC due date, 11/16/2021
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This requirement was not met as evidenced by: Based on staff interviews and records review, the licensee failed to refund part of R1’s June 2020 admission fee which pose potential personal rights violations 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: 11/02/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC9099 (FAS) - (06/04)
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