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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600419
Report Date: 05/16/2023
Date Signed: 05/16/2023 11:30:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
10/25/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20211025132301
FACILITY NAME:QUALITY CARE HOMES, LLC 4FACILITY NUMBER:
385600419
ADMINISTRATOR:FAROL, FERNANDFACILITY TYPE:
740
ADDRESS:475 EUCALYPTUS DRIVETELEPHONE:
(415) 564-6318
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:0CENSUS: 0DATE:
05/16/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Caregiver RosemaTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Reporting Requirements- Licensee failed to notify the Department of financial difficulties/
Financial Distress
INVESTIGATION FINDINGS:
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On 5/16/2023, Licensing Program Analyst (LPA) conducted a unannounced visit to deliver the complaint investigation finding for complaint # 14-AS-202110525132301. LPA met with caregiver, Rose and explained the purpose of today's visit. Caregiver called and informed the administrator of LPA's visit.

Regarding to allegations of - Reporting Requirements- Licensee failed to notify the Department of financial difficulties, in October 2021, the Department received a notification that the facility has not paid rent for 12 months and the landlord would be taking further actions.

As part of the investigation, LPA interviewed the administrator/licensee who acknowledged that the facility was having financial difficulties due to the pandemic and that the facility did not report it to the Department.

In addition, the Department has completed an audit and concluded that licensee did not establish an adequate financial plan as the licensee did not provide requested information or documentation to the Department.

After the investigation, this allegation is substantiated.

Based on observations and information gathered, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.
Deficiency cited today under California Code of Regulations, Title 22, Div 6, follows on LIC 9099D.

Appeal Rights given.
Report reviewed and discussed with caregiver and with Fernand Farol over the phone.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
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-20211025132301
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: QUALITY CARE HOMES, LLC 4
FACILITY NUMBER: 385600419
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/23/2023
Section Cited
CCR
87213
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87213 Finances...The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents;
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The licensee will develop an action plan to ensure compliance and will submit a copy of the plan to CCL by 5/23/2023.
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This requirement is not met as evidenced by the licensee did not provide requested information or documentation to CCL to proof that the facility is in compliance with this regulation which poses an immediate risk for 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2