385600235-5-5-2021-14-AS-KHOS-C2VP59-20210510110021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600235
Report Date: 05/04/2021
Date Signed: 05/05/2021 10:20:19 AM

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
04/08/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210408094555

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: 38	DATE:	05/04/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator, Naoko Jones		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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-Some residents do not have linen changes in a timely manner
-Facility does not have scheduled activities
-Facility staff are not reporting incidents as required
-Facility Administrator did not complete the required 80 hour RCFE Certification Class
-Facility staff have not received required training

INVESTIGATION FINDINGS:

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On 5/4/2021, 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 some residents do not have linen changes in a timely manner, LPA Han reviewed the facility's Housekeeping schedule, interviewed the Director of Dining and Housekeeping, the staff members and the residents. The Director of Dining and Housekeeping stated that Housekeeping services is scheduled on a weekly basis for all residents and linen change is part of the service. If a resident refuses the Housekeeping service on the scheduled day, the housekeeper would go back again on another day of that same week and attempt to convince the resident to accept the service.
The staff also reported that the Housekeeping service is provided on a weekly basis and if the linen is soiled in-between, they would change it. Furthermore, The residents confirmed that they receive Housekeeping service once a week and the service includes linen changes. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

**Report 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: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

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-20210408094555

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: 05/04/2021

NARRATIVE

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Regarding to facility does not have scheduled activities, LPA Han reviewed the weekly Activity Calendar, interviewed the Director of Activity, the residents and the Responsible Parties. The Director of Activity explained that the Activity calendar is being created on a weekly basis and it is being delivered to the residents, emailed to the family members and posted by the Temple which is the main Activity room. The residents concurred that they receive the weekly Activity calendar as well as the Responsible Parties and they are aware when the Activities take place.
The Director of Activity reported that they have not received any concerns regarding the Activity program recently but during the beginning of the Pandemic, one resident expressed unsatisfactory of cancelling all the group activities. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Regarding to staff are not reporting incidents, LPA Han reviewed the Incident Reports that were submitted by the facility to the Licensing Office and validated it that those reports were faxed on time. In addition, LPA Han interviewed the Director of Resident Care regarding to the facility's incident reporting protocols and she stated that the staff member who discovered the incident completes the Internal Incident Report and then the staff members would proceed with other protocols including notifying the Responsible Parties. LPA Han interviewed Medication Manger who stated that when there is an incident, they complete a list of protocols including but not limiting to notifying the Responsible Party. LPA Han interviewed Medication Technician who stated that when there is an incident, they make sure the resident is safe and proceed with other actions such as reporting it to the respective Responsible Party. LPA Han spoke to the Responsible Parties and they confirmed that they were notified in a timely manner for incidents including but not limiting to falls.
Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

** Report Continued on next page**

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20210408094555

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: 05/04/2021

NARRATIVE

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Regarding to facility Administrator did not complete the required 80 hour RCFE Certification Class, the 80 hour training record was not received, however, in order for the Administrator to apply for the Initial Administrator Certification, one of the requirement was to submit the training records. LPA Han reviewed the Administrator Certifications since 2012 and validated that the Administrator obtained the Administrator Certification in 2012 and it is current.
Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Regarding to the facility staff have not received required training, LPA Han reviewed in-service records, interviewed the Administrator, the staff members, the Responsible Parties and the residents. The Administrator explained that due to the Pandemic, most of the staff training classes were done on-line but some were still completed in person. The staff members concurred that they were trained but mostly on-line. The residents expressed that the staff members are trained to care for them and the Responsible Parties witnessed that staff members were knowledgeable of their job duties and they were aware of the resident's daily routines.
Based 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 allegations are 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: 05/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021

LIC9099 (FAS) - (06/04)

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