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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210071
Report Date: 10/03/2022
Date Signed: 10/03/2022 10:17:28 AM

Document Has Been Signed on 10/03/2022 10:17 AM - It Cannot Be Edited

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
FACILITY NAME:NORCAL CARE HOMES, INC.FACILITY NUMBER:
419210071
ADMINISTRATOR:RUSSLYN OLGA A GUEVARRAFACILITY TYPE:
735
ADDRESS:460 BODEGA STREETTELEPHONE:
(650) 377-2530
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 3CENSUS: 3DATE:
10/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Licensee, Fatollah GlichlooTIME COMPLETED:
10:25 AM
NARRATIVE
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On October 3, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow-up on a visit that LPA conducted on 7/18/2022 in relation to an incident that occurred on July 14, 2022 and deliver the findings of the Investigation Branch (IB). LPA met with Licensee, Fatollah Glichloo and Administrator, Russlyn Guevarra joined shortly thereafter. LPA explained the purpose of the visit.

On July 15, 2022, the Licensee reported that Staff #1 (S1) found a hidden camera in the common bathroom. In addition, it was indicated that Staff #2 (S2) acknowledged that the camera belonged to him/her. The Department referred this incident to the Investigation Branch.

Based on the investigation that was conducted by the Department and the information collected, S2 admitted to the Licensee that he/she placed a hidden camera in the common bathroom used by one resident and staff. In addition, interviewed staff indicated the hidden camera belonged to S2, because when staff found the camera and removed it from the bathroom, S2 was asking staff where his/her device was.

During the investigation, it was found that the facility staff who found the camera failed to report this incident to the Licensee immediately, resulting in a delay to notify CCLD. According to the Licensee, it was indicated that S1 found the camera on July 10, 2022, however failed to notify the Licensee until the Ombudsman called the Licensee regarding this incident. Although, the Licensee reported this incident to CCLD on 7/15/22, the facility staff failed to report a serious incident to the Licensee immediately.

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

Report is reviewed with Licensee and administrator and a copy is provided
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2022
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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Document Has Been Signed on 10/03/2022 10:17 AM - It Cannot Be Edited


Created By: Komal Charitra On 10/03/2022 at 09:36 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: NORCAL CARE HOMES, INC.
FACILITY NUMBER: 419210071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/04/2022
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights: (a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following: (3) To be free from corporal or unusual punishment, infliction of pain, humiliation...

Violation of this regulation is evidenced by:
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Facility terminated S2 after the incident occurred. Staff are not allowed to use electronic devices while they are working. In addition, Licensee/Administrator will conduct an in-service training regarding Personal Rights and if staff find something out of place to notify Licensee/Administrator immediately.
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Based on the interviews conducted and the information collected during the investigation, Staff #2 (S2) placed a hidden camera in the common bathroom which is used by residents and staff.
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Type A
10/04/2022
Section Cited
HSC1596.8897(a)(2)

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1596.8897 Prohibited positions or employment; grounds; notice; removal; appeal; petition for reinstatement: (a) The department may prohibit any person from being a member of the board of directors, an executive director, or an officer of a licensee or a licensee from employing, or continuing the employment of...contact with clients of a licensed facility by, any employee, prospective employee, or person who is not a client who has: (2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.

Violation of this regulation is evidenced by
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Facility terminated S2 after the incident occurred. In-service training to be conducted and Licensee/Administrator will provide CCLD with a copy of sign-in sheet by 10/4/22
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Based on the interviews conducted and the information collected during the investigation, Staff #2 (S2) admitted to the Licensee that he/she placed a hidden camera in the common bathroom used by residents and staff
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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.
SUPERVISOR'S NAME:Jackie Jin
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2022


LIC809 (FAS) - (06/04)
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