<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600125
Report Date: 08/11/2022
Date Signed: 08/11/2022 11:44:46 AM


Document Has Been Signed on 08/11/2022 11:44 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:RHODA GOLDMAN PLAZAFACILITY NUMBER:
385600125
ADMINISTRATOR:IRA KURTZFACILITY TYPE:
740
ADDRESS:2180 POST STREETTELEPHONE:
(415) 345-5060
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY:195CENSUS: 129DATE:
08/11/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Ira KurtzTIME COMPLETED:
11:55 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 8/11/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to collect documents regarding a resident's death. LPA met with the administrator and explained purpose of today's visit.

During today's visit, LPA was provided a copy of resident #1 (R1)'s LIC 602- Physician's Report, care plan, documentation related to the incident, facility's incident report, a list of staff who was present during the incident, and communication to the primary physician.

This incident requires further investigation.

No deficiency cited today.

This reported is reviewed and discussed with the administrator. A copy is provided.



SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1