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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601116
Report Date: 08/28/2023
Date Signed: 10/31/2023 10:30:44 AM


Document Has Been Signed on 10/31/2023 10:30 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/30/2023 03:47 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

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Amended Report

On 8/28/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning a report of suspected abuse received on 8/7/23. LPA met with Shirley Cheung, Care Coordinator Director & Deborah Suarez, Assistant General Manager. LPA explained the purpose of today's visit.

In regard to the report, resident (R1) mentioned that a private duty aide (PDA) sexually abused him/her.

Based on record reviews & interviews, in the admission agreement, pages 6-7 pertaining to Private Duty Aides, Outside Services, R1 is allowed to hire, but hired PDA is to follow rules in the community. The PDA is fingerprinted through the agency. PDA was removed from the facility when the report was made. Currently, facility has suggested to residents to hire from the facility's preferred agencies.

Document to be submitted LPA regarding records for the Private Duty Aide.

No deficiencies cited today.

Report was discussed and a copy of the report is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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