380540130-1-24-2023-14-AS-CSMH-CNFUS2-20230126144935

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 380540130
Report Date: 01/24/2023
Date Signed: 01/24/2023 11:41:27 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
09/06/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220906170901

FACILITY NAME:	ST. FRANCIS MANOR I		FACILITY NUMBER:	380540130
ADMINISTRATOR:	ELMORALY, AMAL		FACILITY TYPE:	740
ADDRESS:	1450 PORTOLA DRIVE		TELEPHONE:	(415) 564-8794
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94127
CAPACITY:	12	CENSUS: 2	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Staff, Mohamed Elmoraly		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Resident's are left in a soiled diaper for a long period of time.
Staff yell at the resident's in care.

INVESTIGATION FINDINGS:

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On 1/24/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14- AS-20220906170901. LPA met with staff, Mohamed Elmoraly and explained the purpose of the visit.

Regarding to allegation of resident's are left in a soiled diaper for a long period of time, the reporting party stated that when the reporting party arrived at the facility, resident #1 (R1)'s diaper was soiled but the reporting was not sure how long the resident was left in soiled diapers.

As part of the investigation, LPA observed resident #2 (R2), and resident #3 (R3) as resident #1 (R1) was discharged, LPA observed both residents to be cleaned, no smell of unpleasant odor, and dressed comfortably. According to R3, facility staff is very hard working, they cleaned them right away unless they are busy with other residents then they would have to wait a little longer.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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 5

Control Number 14-AS-20220906170901

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: ST. FRANCIS MANOR I	FACILITY NUMBER: 380540130
	VISIT DATE: 01/24/2023

NARRATIVE

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LPA also interviewed 8 interdisciplinary team members from the home health and hospice agencies that conducted weekly visits at the facility and all of them reported that during their weekly visits, they observed residents to be cleaned, appropriately dressed, and staff was attentive to residents.

Base on interviews during the course of investigation, this allegation is unsubstantiated.

Regarding to staff yelled at resident's in care, the reporting party stated that the reporting party has observed residents being yelled at by facility staff.

As part of the investigation, LPA interviewed the facility manager who denied the allegation and stated that they never yelled at any residents.

LPA also interviewed R3 and resident #4 (R4) who stated that facility staff is very respectful and no one yelled at them. R3 also stated that facility staff is very hard working, and caring to all the residents.

Furthermore, LPA interviewed 8 interdisciplinary team members from 2 home health and hospice agencies and all of the reported that they have never observed facility staff were disrespectful and yelled at the residents.

Base on interviews, and observations during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with staff. A copy is provide.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

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
09/06/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220906170901

FACILITY NAME:	ST. FRANCIS MANOR I		FACILITY NUMBER:	380540130
ADMINISTRATOR:	ELMORALY, AMAL		FACILITY TYPE:	740
ADDRESS:	1450 PORTOLA DRIVE		TELEPHONE:	(415) 564-8794
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94127
CAPACITY:	12	CENSUS: 2	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	10:55 AM
MET WITH:	Staff, Mohamed Elmoraly		TIME COMPLETED:	11:50 AM

ALLEGATION(S):

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Resident's developed pressure injuries while in care.
Staff refused to apply topical medication to resident.
Resident's hygiene needs are not being met.

INVESTIGATION FINDINGS:

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On 1/24/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14- AS-20220906170901. LPA met with staff, Mohamed Elmoraly and explained the purpose of the visit.

Regarding to allegation of- resident developed pressure injuries while in care, according to the reporting party, resident #1(R1) developed a pressure ulcer while at the facility.

As part of the investigation, LPA interviewed the facility manager who denied the allegation and stated that R1 was only at the facility for a couple of weeks and R1 was admitted with pressure ulcer.

LPA also interviewed the visiting home health Registered Nurse who confirmed that R1 was admitted pressure ulcer.

After the investigation, this allegation is deemed to be unfounded as R1 was admitted with pressure ulcer and did not develop it during R1's stay at the facility. However, the facility was not able to provide a copy of R1's pre-admission appraisal and the administrator acknowledged that this was not completed for R1. This deficiency will be cited on LIC 809 and LIC809 D under case management.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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 5

Control Number 14-AS-20220906170901

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: ST. FRANCIS MANOR I	FACILITY NUMBER: 380540130
	VISIT DATE: 01/24/2023

NARRATIVE

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Regarding to allegation of - staff refused to apply topical medication to resident, the reporting party stated that facility stopped a hospice staff from applying cream to resident #1(R2)'s back.

As part of the investigation, LPA interviewed facility manager who admitted the above allegation and stated that a home health aide from the hospice agency was applying a prescribed cream on R2's back so the facility manager stopped this individual as it was not within this individual's scope of practice to perform this task as this should be done by the nurse(s) from the hospice agency.

LPA interviewed the Director of Nursing at the hospice agency who confirmed that the home health aide is not supposed to apply any prescribed/medication cream on residents.

After the investigation, this allegation is deemed to be unfounded as the facility staff was not a skilled professionals. Therefore, they are not supposed to apply prescribed cream on resident(s).

Regarding to allegation of - resident's hygiene needs are not being met, the reporting party stated that based on his/her observation, the shower room was too small for residents to shower. Therefore, his/her reported that resident was not provided with showers.

As part of the investigation, LPA interviewed the facility manager who denied the allegation and stated that they provided showers, bed baths, and other activities of daily living tasks to all the residents when needed.

LPA also interviewed resident #3 (R3) and resident #4 (R4) who stated that facility staff assisted them with showers or bed bath when they needed it. R3 preferred a bed bath and R4 received a shower everyday. Both residents reported that they are satisfied with the care that they are provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 14-AS-20220906170901

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: ST. FRANCIS MANOR I	FACILITY NUMBER: 380540130
	VISIT DATE: 01/24/2023

NARRATIVE

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Furthermore, during the initial investigation visit on 9/14/2022, LPA observed R1, R2 and R3 to be cleaned, tidy, no odor, appropriately dressed and neat.

Based on observation, and interviews, this allegation is deemed to be unfounded as the residents are getting showers as they desired.

Based on observation, and interview during the course of the investigation, this complaint is deemed to be UNFOUNDED, meaning that these allegations were false, could not have happened and/or is without a reasonable basis as during the investigation.

This report is reviewed and discussed with staff.

A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5