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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 389210019
Report Date: 08/04/2023
Date Signed: 08/04/2023 10:27:31 AM

Unsubstantiated


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
07/28/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230728152301
FACILITY NAME:SAN FRANCISCO ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
389210019
ADMINISTRATOR:CALVIN LATIMOREFACILITY TYPE:
735
ADDRESS:887 POTRERO AVE.TELEPHONE:
(415) 206-6300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:55CENSUS: 38DATE:
08/04/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator, Calvin LatimoreTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff engaged in a verbal altercation with another staff in the presence of residents.
INVESTIGATION FINDINGS:
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On August 4, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Calvin Latimore and Registered Nurse, Charisse Li and explained the purpose of the visit.

Regarding the allegation that staff engaged in a verbal altercation with another staff in the presence of residents, according to the reporting party, Staff 1 (S1) was going to accompany Resident 1 (R1) to get food, however Staff 2 (S2) immediately interrupted S1 with anger, loudly exclaiming that S1 cannot leave with R1 during work hours.

During the investigation, LPA interviewedthe administrator, staff and resident. According to the administrator and staff interviewed, on 7/16/23, S2 and the House Supervisor on shift notified administrator that S1 left the facility with R1 without notifying team leader. (CONT. TO 9099C).
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
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 3
Control Number 14-AS-20230728152301
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: SAN FRANCISCO ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 389210019
VISIT DATE: 08/04/2023
NARRATIVE
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In addition, administrator was notified by S2 and the House Supervisor that S2 told S1 to not leave the facility to accompany R1 during work hours, however S1 still left the facility with R1.

LPA interviewed S2 and S2 denied this allegation. According to S2, he/she did not yell or shout at S1 and/or R1. S2 indicated that he/she asked S1 if S1 notified House Supervisor regarding leaving with R1 and told S1 that he/she should not leave during work hours because Rehab staff are assigned to accompany residents on their outings.

Furthermore, LPA interviewed R1, R1 did not remember S2 being loud or yelling at S1 in his/her presence.

Although the above allegation may have happened or are valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with Administrator and Registered Nurse, and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3