385600125-2-15-2024-14-AS-ACON-D3SUJC-20240328153718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600125
Report Date: 02/15/2024
Date Signed: 02/15/2024 10:26:56 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/04/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231004150448

FACILITY NAME:	RHODA GOLDMAN PLAZA		FACILITY NUMBER:	385600125
ADMINISTRATOR:	IRA KURTZ		FACILITY TYPE:	740
ADDRESS:	2180 POST STREET		TELEPHONE:	(415) 345-5060
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94115
CAPACITY:	195	CENSUS: 146	DATE:	02/15/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Adrienne Fair - Assistant Executive Director		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

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- Facility staff caused bruising to resident
- Facility staff did not notify resident's physician of injury
- Facility staff did not notify resident's family of injury
- Resident sustained multiple falls due to lack of supervision
- Facility staff sexually abused resident
- Resident sustained a head injury due to lack of supervision

INVESTIGATION FINDINGS:

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On 02/15/2024, Licesning Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations above. LPA met with Adrienne Fair and explained the purpose of today's visit.

The Department investigated the allegations recieved and discovered that in regards to the resident being sexually abused, it was discovered that during resident transfers R1 would constantly cover her "private area" and would keep her legs close shut when staff would change her and transfer her and the bruisng would be caused where her hands were located during those transfers. No other residents reported abuse, mistreatment, or any complaints regarding the facility or staff.

Continued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231004150448

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: RHODA GOLDMAN PLAZA	FACILITY NUMBER: 385600125
	VISIT DATE: 02/15/2024

NARRATIVE

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Page 2 - LIC9099

Regarding resident sustaining a head injury, it was reported that on 09/19/2023, R1 sustained a witnessed fall from her wheelchair in an activity room. Staff did an assessment of R1 and sent R1 to the hospital for evaluation. Medical record from the hospital reflected that R1 did suffer an injury, but based on interviews R1 leaned too far forward and fell out of the wheelchair hitting their head. Staff were unable to get to R1 fast enough to prevent her from falling. As a result R1 obtained a new cushion for their wheelchair that prevents R1 from being able to rock or lean forward far enough to fall out again. In regards to other bruising of the resident, through interviews it was discovered that staff technique in rolling and positioning the resident may have caused bruising accidentally by pulling the clothes or sheets to help position the resident. There was no other evidence of abuse taking place that would intend it was done purposely. According to interviews, and hospital records, the physician of R1 was notified of injuries when they occurred as well as the facility notifying the responsible party of R1. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

LIC9099 (FAS) - (06/04)

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