410507207-3-22-2024-14-AS-KHOS-D3QGUC-20240326053855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 410507207
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:22:31 PM

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
03/21/2024 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240321150559

FACILITY NAME:	P.A.R.C.A. CEDAR STREET HOUSE		FACILITY NUMBER:	410507207
ADMINISTRATOR:	CARLETTE L PHIPPS		FACILITY TYPE:	735
ADDRESS:	721 CEDAR STREET		TELEPHONE:	(650) 226-3798
CITY:	SAN CARLOS	STATE: CA	ZIP CODE:	94070
CAPACITY:	8	CENSUS: 7	DATE:	03/22/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	CEO, Diana Conti		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility staff is storing expired milk.
Facility P&I ledger is inaccurate.

INVESTIGATION FINDINGS:

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On March 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with CEO, Diana Conti, Interim Director of Program, Patrice Clay, Interim Director, Marites De La Cruz and explained the purpose of the visit.

Regarding the allegation, facility staff is storing expired milk, according to the reporting party, facility stored expired milk in the refrigerator. During the visit, LPA observed the refrigerator in the kitchen and the refrigerators located in the garage. LPA observed expired milk in the kitchen refrigerator. The expiration date observed on the gallon of milk was dated 03/21/2024.

Regarding the allegation, facility P&I ledger is inaccurate, according to the reporting party, the facility ledgers and balances did not match, the receipts were not saved, and the ledger was not initialed routinely by residents.

During the investigation, LPA interviewed the CEO and staff. According to interviews, it was acknowledged that based on all clients' ledger audit, there was one client (R1) whose ledger was illegible and had possible math errors. During the visit, LPA observed R1’s ledger and observed on 5/14/2023, R1 did not sign off on purchasing ice cream twice.

Therefore, based on the records reviewed, interviews conducted, and information collected, the allegations facility staff is storing expired milk and facility P&I ledger is inaccurate 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.

Continue to 9099A

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
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 3

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
03/21/2024 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240321150559

FACILITY NAME:	P.A.R.C.A. CEDAR STREET HOUSE		FACILITY NUMBER:	410507207
ADMINISTRATOR:	CARLETTE L PHIPPS		FACILITY TYPE:	735
ADDRESS:	721 CEDAR STREET		TELEPHONE:	(650) 226-3798
CITY:	SAN CARLOS	STATE: CA	ZIP CODE:	94070
CAPACITY:	8	CENSUS: 7	DATE:	03/22/2024
		UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	CEO, Diana Conti		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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3
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7
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9

Staff did not ensure that an adequate amount of food is stored at the facility.
Staff are not serving a variety of foods to residents in care.
Staff did not dispose of a discontinued medication.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On March 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with CEO, Diana Conti, Interim Director of Program, Patrice Clay, Interim Director, Marites De La Cruz and explained the purpose of the visit.

Regarding the allegation, staff did not ensure that an adequate amount of food is stored at the facility, according to the reporting party, there was not many fresh foods on site. During the visit, LPA toured the facility and observed food supply. LPA observed 2 days for perishables and 7 days non-perishables present.

Regarding the allegation, staff are not serving a variety of foods to residents in care. According to the reporting party, the facility is not providing clients with a variety of foods. During the visit, LPA observed 2 days for perishables and 7 days non-perishables present. In addition, LPA observed two weeks food menu posted on the kitchen refrigerator. LPA observed on the food menu for 3/22/2024 that clients will be having chicken pasta with salad and corn for dinner. LPA observed all required ingredients for dinner present at the facility. During the visit, LPA interviewed facility cook and he/she indicated that he/she is making chicken pasta with salad and corn for dinner.

Regarding the allegation staff did not dispose of a discontinued medication, according to the reporting party, the facility did not dispose of a client’s medication who no longer resides at the facility. During the investigation, LPA reviewed all clients’ medications. LPA did not observe any discontinued or expired medications at the facility. According to Interim Director, a thorough audit was done for all clients’ medication to ensure all medications were up to date with physician’s orders were maintained for each one.

Therefore, based on interviews conducted, information collected, and observations the above allegations are determined to be UNSUBSTANTIATED. Report is reviewed with CEO, Diana Conti and a copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
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: 2 of 3

Control Number 14-AS-20240321150559

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: 03/22/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/23/2024 Section Cited CCR 80076(a)(1)	1 2 3 4 5 6 7	80076 Food Services: (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients... Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Interim Program Director immediately threw out the milk. Deficiency is cleared and corrected.
	8 9 10 11 12 13 14	Based on observations, LPA observed a gallon of expired milk in the kitchen fridge. Expiration date was 3/21/2024.	8 9 10 11 12 13 14
Type A 03/23/2024 Section Cited CCR 80026(h)	1 2 3 4 5 6 7	80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents: (h) Each licensee shall maintain accurate records of accounts of cash resources... Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	According to the Licensee, an electronic system has been implemented a budget sheet to be completed monthly. In addition, a new policy has been implemented where two staff on each shift will count all clients' P&I money daily. Every month the budget sheet will go to PARCA's finance department for review.
	8 9 10 11 12 13 14	Based on staff interviewed, it was acknowledged that based on all resident’s ledger audit, there was one client (R1) whose ledger was illegible and had possible math errors. During the visit, LPA observed R1’s ledger and observed on 5/14/2023, R1 did not sign off on purchasing ice cream twice.	8 9 10 11 12 13 14

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: 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)

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