385600019-8-23-2021-14-AS-KHOS-C69PDQ-20210826111355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600019
Report Date: 08/23/2021
Date Signed: 08/23/2021 11:01:39 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/07/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210707083128

FACILITY NAME:	PROVIDENCE PLACE		FACILITY NUMBER:	385600019
ADMINISTRATOR:	KNOP, GALINA		FACILITY TYPE:	740
ADDRESS:	2456 GEARY BLVD.		TELEPHONE:	(415) 359-9700
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94115
CAPACITY:	34	CENSUS: 23	DATE:	08/23/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Caregiver, Yvette Arevalo		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff are not assisting resident with incontinence.
Staff are not assisting resident with hygiene.
Staff left resident in bed with no clothing.
Staff are not allowing family member to take resident on outing.
Staff are restricting family visits to resident.

INVESTIGATION FINDINGS:

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On 8/23/21, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint inspection to deliver the findings. LPA met with caregiver, Yvette Arevalo and explained the purpose of the visit.

Regarding to staff are not assisting resident with incontinence, staff are not assisting resident with hygiene and staff left resident in bed with no clothing, during LPA's visit on 7/14/2021, LPA observed resident in bed appeared to be calm and comfortable, the linen was cleaned, there was no scent of odor coming from the resident and from the room, the resident was neatly dressed, and hair was cobmbed.

LPA interviewed the Health and Wellness Director and the staff members and they denied the allegations. They stated that incontinence care is being provided every 2 hours or as needed and they have never left the resident in bed with no clothes on. When it comes to resident's hygiene, they stated that those tasks are being performed daily such as providing showers, brushing teeth, washing hands, combing hair, etc.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

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-20210707083128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PROVIDENCE PLACE	FACILITY NUMBER: 385600019
	VISIT DATE: 08/23/2021

NARRATIVE

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In addition, LPA interviewed R1's Responsible Party who stated that he/she visits the resident few times per week, some of those visits were pre-scheduled due to the Pandemic and some were not and he/she has never observed R1 having poor hygiene, having odor, not wearing any clothes and having soiled attends.

Furthermore, LPA interviewed other resident's Responsible Parties regarding the facility's overall care performance, and they reported that the residents are well cared for; they have never observed their loved ones not wearing any clothes, and having poor hygiene. A couple of them with female residents residing at the facility stated that they were really impressed with the facility when they observed the facility provided manicure to their loved ones.

Base on record review and interviews 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 allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20210707083128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PROVIDENCE PLACE	FACILITY NUMBER: 385600019
	VISIT DATE: 08/23/2021

NARRATIVE

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Regarding to staff are restricting family visits to resident, there is no addition information forthcoming from the Complainant. LPA reviewed the visitor's sign-in log and observed that there were visitors visiting the facility on a daily basis. LPA interviewed the Health and Wellness Director who denied the allegation and stated that due to the Pandemic, the facility is requesting the family members to call and schedule the visits ahead of time to ensure the designated visitation area(s) is not overly crowded and if there are multiple visitors at the same time, the facility would make other alternate space arrangements to accommodate everyone and to ensure social distancing is maintained.

In addition, LPA interviewed R1's Responsible Party who stated that the facility has never restricted the visits and it is understandable that the facility is asking the visits to be scheduled ahead of time to ensure everyone's safety. Furthermore, LPA interviewed other Responsible Parties who also validated that their visits were never restricted and they agreed with calling the facility ahead of time to schedule to visit to ensure everyone's safety.

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

Although the above investigation 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.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20210707083128

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PROVIDENCE PLACE	FACILITY NUMBER: 385600019
	VISIT DATE: 08/23/2021

NARRATIVE

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Regarding to staff are not allowing family members to take resident on an outing, there is no additional information forthcoming from the Complainant. LPA interviewed the Health and Wellness Director who denied the allegation and stated that the Complainant has never requested to take the resident out on an outing and since the Department updated the visitation and outing guidelines, the facility has honored serval residents going out on an outing with their family members.

As part of the investigation, LPA interviewed R1's Responsible Party who stated that he/she has never requested to take R1 out on an outing due to the Pandemic and at the same time, he/she has never been told that he/she is not allowed to do so.

In addition, LPA interviewed the other resident's Responsible Parties and they validated that they have never been rejected by the facility to take their loved ones out on an outing and at the same time, they also did not feel that it was safe to do so due to the Pandemic.

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

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

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021

LIC9099 (FAS) - (06/04)

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