385600235-7-22-2021-14-AS-KHOS-C69KXX-20210826081813

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600235
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:38:35 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
03/05/2020 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20200305140351

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: 40	DATE:	07/22/2021
		UNANNOUNCED	TIME BEGAN:	02:25 PM
MET WITH:	Executive Director, Naoko Jones		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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-- Residents sustained injuries from falls while in care.
-- Staff leaving residents in soiled diapers for extended periods of time.
-- Staff was unable to locate a resident while in care
-- Staff failed to notify authorized representative of residents incidents.
-- Staff administered discontinued medication to a resident

INVESTIGATION FINDINGS:

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On 7/22/2021, on behave of Licensing Program Analyst Michael Garcia, Licensing Program Analyst (LPA) Han conducted an unannounced complaint visit to deliver the finding on the above allegations. LPA met the Executive Director, Naoko Jones.

-- Residents sustained injuries from falls while in care: According to facility records, Resident 1 (R1) had an unwitnessed mechanical fall while trying to get out of bed inside the apartment on May 31, 2018. Injuries were noted in R1’s knees and forehead.

According to staff interviews, Staff 1 stated that R1 has no fall prevention plan due to R1 is independent and is low risk for falls.

CONTINUE ON NEXT PAGE...

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: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

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-20200305140351

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: 07/22/2021

NARRATIVE

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According to R1’s physician’s report, R1 is ambulatory and has no motor impairment. There was no special instruction in R1’s physician’s report for the facility to follow to prevent falls prior to incident.

-- Staff leaving residents in soiled diapers for extended periods of time: According to administrator, continence care is provided to residents every 2 hours; hourly if a resident has a condition. Facility staff logs continence care provided in a chart inside the resident's apartment per administrator. According to facility records, continence care was provided to Resident 5 (R5) regularly for June 2019, as documented by facility staff.

-- Staff was unable to locate a resident while in care: According to records review conducted, on August 23, 2019, CCL unsubstantiated a complaint allegation that Resident 4 (R4) left the facility unauthorized. According to R4’s physician’s report, R4 was able to leave the facility unattended, can communicate needs and follow instructions. According to facility records, R4 signed out prior to leaving the facility and signed in upon return.

-- Staff failed to notify authorized representative of residents incidents: According to staff interviews, S1 stated that the person responsible for the resident is notified of incidents verbally. According to facility records, the May 31, 2018 fall incident was reported to the person responsible for the resident as documented by facility staff.

-- Staff administered discontinued medication to a resident: According to Physicians Orders dated March 13, 2019, the medication FUROSEMIDE (aka LASIX) 40 mg is to be discontinued for R2. According to facility records, this medication was last administered to R2 around noon of March 2, 2019, as documented by facility staff.

The allegations were deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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