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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600024
Report Date: 10/26/2022
Date Signed: 10/26/2022 11:57:59 AM


Document Has Been Signed on 10/26/2022 11:57 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:PETER CLAVER COMMUNITYFACILITY NUMBER:
385600024
ADMINISTRATOR:TONJA SAGUNFACILITY TYPE:
736
ADDRESS:1340 GOLDEN GATE AVENUETELEPHONE:
(415) 749-3800
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:32CENSUS: 18DATE:
10/26/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Case Manager, Kim Walker TIME COMPLETED:
12:10 PM
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On 10/26/2022, Licensing Program Analyst (LPA), Murial Han conducted a case management visit to delivery the finding of an incident that was reported to Community Care Licensing (CCL). LPA met with case manager, Kim Walker and explained the purpose of today's visit.

On 7/20/2022, the facility reported a serious incident concerning resident #1 (R1) was saying good bye to a friend and mentioned something about the window in R1's room. Staff was notified of such conversation and checked on R1 and R1 declined to open the door. Staff called 911, walked outside of the facility, attempted to talk to R1 from the window and discovered R1 was laying on the ground. R1 was transported to the hospital where R1 was declared deceased.

On 7/21/2022, Licensing Program Analyst (LPA) Jaime Vado made a case management visit regarding the incident and initiated an investigation.

During the investigation, the Department collected documentation and conducted interviews.

This is an independent living facility and residents have the freedom to come and go as they desire. According to facility staff and residents, on the day of the incident, R1 appeared fine and R1 was being normal self that morning and the days prior to the incident. In addition, staff reported checking on R1 during the day of the incident.

Based on interviews, and record reviews there is no preponderance evidence of lack of supervision and neglect from the facility, therefore, this incident is deemed to be unfounded.

No deficiency cited. This report is discussed and reviewed with the case manager. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2022
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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