385600235-5-12-2021-14-AS-JMOS-C2YSXM-20210513141608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600235
Report Date: 05/12/2021
Date Signed: 05/12/2021 04:23:03 PM

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
04/29/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210429160856

FACILITY NAME:	KOKORO ASSISTED LIVING		FACILITY NUMBER:	385600235
ADMINISTRATOR:	NAOKO JONES		FACILITY TYPE:	740
ADDRESS:	1881 BUSH ST		TELEPHONE:	(415) 776-8066
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	61	CENSUS: 39	DATE:	05/12/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator, Naoko Jones		TIME COMPLETED:	02:36 PM

ALLEGATION(S):

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Residents are not provided with plastic utensils- forks and spoons

INVESTIGATION FINDINGS:

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On 5/12/2021, Licensed Program Analyst (LPA) Han conducted a follow-up inspection with the Administrator, Naoko Jones over the phone to deliver the findings. Due to COVID-19 and health and safety concerns, LPA Han was not present in the facility.

Regarding to residents are not provided with plastic utensils, the original complaint was residents are not provided with forks and spoons but upon investigation, LPA Han discovered that the actual complaint was the residents were not provided with plastic utensils such as forks and spoons.

As part of the investigation, LPA Han reviewed the order confirmation and a proof when the order was received, interviewed the Director of Dining and Housekeeping, interviewed the staff members for the morning and the afternoon shifts and interviewed the residents. All of them stated that during the days when the facility ran out of the plastic utensils, the residents were provided with chopsticks and small wooden spoons. For the residents who did not know how to use chopsticks, they were offered silverware and/or they used the cleaned plastic utensils which they saved from the previous meals.

This report is continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

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-20210429160856

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: KOKORO ASSISTED LIVING	FACILITY NUMBER: 385600235
	VISIT DATE: 05/12/2021

NARRATIVE

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In addition, the staff members reported that most of the residents prefer chopsticks and they have not gotten any complaints from the residents regarding not having plastic utensils.

During the interview with the residents, they validated that they prefer chopsticks over other utensils and one of them stated, " I always get what I want".

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 allegation is UNSUBSTANTIATED.

Exit interview conducted with the facility's Administrator over the phone. The facility Administrator will receive this LIC9099 report through email to sign and email it back to LPA Han.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2021

LIC9099 (FAS) - (06/04)

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