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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601120
Report Date: 03/22/2024
Date Signed: 03/22/2024 06:29:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/19/2024 and conducted by Evaluator Grace Donato
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240319093711
FACILITY NAME:PHIL & GRACE HOMES INC.FACILITY NUMBER:
385601120
ADMINISTRATOR:BIGGENS, OMOZELEFACILITY TYPE:
735
ADDRESS:1658 YOSEMITE AVETELEPHONE:
(415) 279-0344
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94124
CAPACITY:4CENSUS: 3DATE:
03/22/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Osamudiami AigbuzaTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff are not maintaining accurate and consistent resident records.
INVESTIGATION FINDINGS:
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On 3/22/2024, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Administrator Osamudiami Aigbuza and explained the purpose of today's visit.

Regarding the allegation of staff are not maintaining accurate and consistent resident records, the Reporting Party (RP) stated that the home struggles to maintain their files and of particular concern is inconsistencies with the MAR.

Based on record reviews, LPA observed that the MAR (Medical Administration Records) are updated every day. However, upon reviewing each resident’s facility records, LPA observed that there are inconsistencies with record keeping. One resident (R1) out of three resident records don’t have an LIC601(Identification & Emergency Information) & LIC602 (Physicians Report). R3 doesn’t have LIC9172 (Functional Capabilities Assessment).

Therefore, based on records review and information collected, the above allegation is
determined to be SUBSTANTIATED. Deficiencies of the California Code of Regulations, Title, 22
cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A copy of this report and the Appeal Rights are provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
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-20240319093711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: PHIL & GRACE HOMES INC.
FACILITY NUMBER: 385601120
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/23/2024
Section Cited
CCR
80069(a)
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80069 Client Medical Assessment (a)Except for licensees of ARFs , prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client, as specified in Section 80069(c), which enables the licensee to determine his/her ability to provide necessary health related services to the client. The assessment shall be used in developing the Needs and Services Plan.
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Licensee to submit a plan on how the facility will address and update the client records. Licensee to submit completed records to LPA when finished. Licensee to submit plan by POC due date.
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This requirement was not met as evidenced by: Based on record reviews (R1) out of three resident records don’t have an LIC601 & LIC602 which poses an immediate health, safety, or personal rights risk to persons in care.
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Type A
03/23/2024
Section Cited
CCR
80069.2(a)
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80069.2 Functional Capabilites Assessment (a)In order to determine whether the facility's program meets a client's services needs, the licensee of an ARF shall assess the client's need for personal assistance and care by determining his/her functional capabilities. The assessment shall be in writing, shall be used in developing the Needs and Service Plan, and shall include, but not be limited to the following activities:
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Licensee to submit a plan on how the facility will address and update the client records. Licensee to submit completed records to LPA when finished. Licensee to submit plan by POC due date.
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This requirement was not met as evidenced by: Based on record reviews R3 doesn’t have LIC9172 which poses an immediate health, safety, or personal rights risk to persons 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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2