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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500295
Report Date: 10/02/2023
Date Signed: 10/02/2023 08:05:51 PM


Document Has Been Signed on 10/02/2023 08:05 PM - 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:HERITAGE ON THE MARINAFACILITY NUMBER:
380500295
ADMINISTRATOR:MARY LINDEFACILITY TYPE:
741
ADDRESS:3400 LAGUNA ST.TELEPHONE:
(415) 202-0300
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94123
CAPACITY:109CENSUS: 74DATE:
10/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Mary LindeTIME COMPLETED:
10:50 AM
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 On 10/2/23, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning incident report received. LPA met with Administrator Mary Linde. LPA explained the purpose of today's visit.

On 8/14/23 Licensing received a report regarding a resident (R1) that had suicidal ideation. An SOC 341 was also filed. Based on records reviews, R1 was in close monitoring. R1 was assigned a private aide that constantly checks on him/her and is outside the room with the door ajar. R1 has no diagnosis of dementia and family is aware that his/her medications are being managed by the facility.

On 8/12/23, a family member picked up medication for R1. Family member went to facility and directly gave the medication to the resident without facility knowledge. The exchange happened with the private aide not being aware due to R1 leaving after lunch. A nurse checked on the room and no medication was found. Around dinner time, R1 was found in room unrousable. 911 was called and R1 was sent to hospital. On the same day, another round of search was done in the room and an empty bottle of pills was found hidden at the bottom of the open trash bag.

R1 died at the hospital on 8/15/23.

No deficiencies are cited during the visit. Report is reviewed with the administrator and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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