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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600125
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:00:51 PM


Document Has Been Signed on 12/21/2022 12:00 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: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: 143DATE:
12/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Administrator, Ira KrutzTIME COMPLETED:
12:10 PM
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On 12/21/2022, Licensing Program Analyst (LPA) conducted a case management visit to follow-up on a case management visit that was conducted on 8/11/2022 regarding an incident that was reported to CCL by the facility.

On 8/4/2022, facility reported resident #1 (R1) was eating dinner and staff noted R1 ceased breathing, became pale, and was holding own chest and neck. Staff performed Heimlich Maneuver, called 911 and R1 was pronounced deceased by the paramedics.

On 8/11/2022, LPA conducted a case management regarding the incident and collected documents.

Based on R1 doctor's documentation, the cause of death is Aspiration, Chronic Dysphagia, Lewy Body Dementia.

Based on Medical Examiner's report, Manner of Death - Accident and Method of Death- Aspiration Food.

LPA interviewed the assistant administrator who stated that R1 did not required a special diet and R1 did not need assistance with feeding but staff provided supervision during R1's meal times. In addition, the assistant administrator stated that when staff noted R1's condition on 8/4/2022, staff took immediate actions.

Based on the documents provided, LPA observed R1 was not on a special diet and R1 was able to feed self during meals.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: RHODA GOLDMAN PLAZA
FACILITY NUMBER: 385600125
VISIT DATE: 12/21/2022
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Based on staff documentation, when staff #1(S1) observed R1 was having difficulty breathing, turning pale and hold own chest and neck, S1 called for Staff #2 (S2) who is a licensed professional for assistance and when S2 arrived, S2 took over the Heimlich Maneuver from S1 while S1 proceed to call 911. While waiting for the paramedics, S2 administered oxygen to R1.

Based on records review and interviews, there is no lack of supervision and neglect observed,

No deficiency cited today.

This report is reviewed and discussed with administrator.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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