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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 410507207
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:42:52 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
01/12/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240112093523
FACILITY NAME:P.A.R.C.A. CEDAR STREET HOUSEFACILITY NUMBER:
410507207
ADMINISTRATOR:CARLETTE L PHIPPSFACILITY TYPE:
735
ADDRESS:721 CEDAR STREETTELEPHONE:
(650) 226-3798
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:8CENSUS: 7DATE:
02/08/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Carmelita De CastroTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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-Facility is operating out of staffing ratio.
-Staff do not administer resident's medications as prescribed.
-Staff are not adequately trained to meet resident's needs.
INVESTIGATION FINDINGS:
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On February 8, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Caregiver, Carmelita De Castro and explained the purpose of the visit.

Regarding the allegation, facility is operating out of staffing ratio, according to the reporting party, the facility is operating at an unsafe staff to client ratio as the facility has 7 clients and at times there is only one staff working on shift. In addition, during the initial reporting, the reporting party indicated that there is a client (R1) who required 1:1 care.

During the investigation, LPA interviewed the administrator, reviewed staff schedule and interviewed staff. According to the administrator, she acknowledged that there are usually two staff members on schedule in the morning and late afternoon when clients return back from their day programs. In addition, the administrator admitted that although the facility is trying to hire additional staff, at the time, the facility did not have sufficient staff to ensure the staff to client ratio was being met knowing that there is a client who required 1:1 care. Based on staff schedules reviewed from November 2023 - January 2024, there were between 1-2 staff members for 7 clients in the morning and after clients returned from day program, however it was not always consistent each day. Nevertheless, the facility failed to ensure that sufficient staffing was provided to meet CCR 85065.5 Day Staff-Client Ratio for 7 clients every day, in addition the facility failed to ensure additional staff was present to provide care to R1 who required 1:1 care. (Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
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 4
Control Number 14-AS-20240112093523
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: P.A.R.C.A. CEDAR STREET HOUSE
FACILITY NUMBER: 410507207
VISIT DATE: 02/08/2024
NARRATIVE
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Regarding the allegation that staff do not administer resident’s medications as prescribed, according to the reporting party, on 1/9/2024, staff waited until 4:30pm to provide Benzodiazepine Onfi to R1 at 3pm as prescribed by R1's physician which caused R1 to have a seizure.

During the investigation LPA interviewed the administrator, reviewed R1’s medication list and medication orders. According to the administrator, staff called administrator around 4:20pm indicating R1 is having a seizure and administrator instructed staff to not provide R1 his/her seizure medication until R1 was stable. Based on the R1’s seizure log reviewed, on 1/9/2024, R1 did not have a seizure until 4:20pm. According to the administrator, she is unsure why R1 didn’t receive his/her medication at 3pm as prescribed. Based on R1’s physician's order, R1 is to receive Onfi three times a day; 7:30am, one at 3pm, and one at 9pm. Based on interviews conducted and information collected, staff did not administer resident's medication as prescribed by the physician.

Regarding the allegation, staff are not adequately trained to meet resident’s needs, according to the reporting party, R1 was admitted to the facility back in December of 2022, however the facility has not received any trainings on how to support R1’s seizure and when to give R1 medical attention.

During the investigation, LPA interviewed the administrator and requested training documentation. According to the administrator, she has not provided formal training to the staff regarding caring for R1. In addition, the administrator was unable to locate or provide LPA any training records regarding caring for R1 that may have been conducted by the previous administrator.

Therefore, based on the records reviewed, interviews conducted, and information collected, the allegations facility is operating out of staffing ratio, staff do not administer resident's medication as prescribed, and staff are not adequately trained to meet resident's needs 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.

Report is reviewed with Caregiver, Carmelita De Castro and a copy is provided with appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20240112093523
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: P.A.R.C.A. CEDAR STREET HOUSE
FACILITY NUMBER: 410507207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
85065(b)
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85065 Personnel Requirements:
(b) The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

Violation of this regulation is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing on how the facility will ensure there is sufficient staffing to provide care and supervision to meet the needs of all residents. This plan shall include how the facility will ensure a 1:1 caregiver is present to provide care to R1.
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Based on interviews conducted and staff schedules reviewed from November 2023-January 2024; staffing was not consistent as there were between 1-2 staff members for 7 clients in the morning and after clients returned from day program, however R1 required 1:1 care. In addition, the administrator acknowledged that there is not sufficient staffing at the facility.
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Type A
02/09/2024
Section Cited
CCR
80075(b)
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80075 Health Related Services:
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

Violation of this regulation is not met as evidenced by:
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On 2/13/2024, Licensing Program Analyst (LPA) Komal Charitra conducted a visit to deliver amended 9099D page to add a plan of correction for CCR 80075(b). LPA met with Senior Project Manager, David Hernandez and explained the purpose of the visit.
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Based on interviews and record review, R1 has a prescription to receive Onfi 3x a day; 7am, 3pm, and 9pm, however on 1/9/24, the facility staff did not provide R1 his/her Onfi medication at 3pm as prescribed.
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Licensee/Administrator shall conduct in-service training with staff who administer medications to clients and ensure MAR is present and current.
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: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 14-AS-20240112093523
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: P.A.R.C.A. CEDAR STREET HOUSE
FACILITY NUMBER: 410507207
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
80065(a)
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80065 Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs...

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to submit a written plan in writing on how to ensure routine in-service training are conducted and logged in relation to residents and their behaviors. Licensee/administrator to conduct an in-service training regarding caring for R1 and provide LPA a copy of the in-service sign in training log by 2/9/2024.
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Based on interviews conducted, the administrator acknowledged no formal training was provided to the staff in relation to how to care for R1. In addition, the administrator was unable to locate or provide LPA any training documents that may have been provided by the previous administrator.
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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: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4