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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600235
Report Date: 10/12/2021
Date Signed: 10/12/2021 12:31:31 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
08/19/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210819100818
FACILITY NAME:KOKORO ASSISTED LIVINGFACILITY NUMBER:
385600235
ADMINISTRATOR:NAOKO JONESFACILITY TYPE:
740
ADDRESS:1881 BUSH STTELEPHONE:
(415) 776-8066
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:61CENSUS: 40DATE:
10/12/2021
UNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Administrator, Naoko JonesTIME COMPLETED:
12:40 PM
ALLEGATION(S):
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Resident was not accorded the right for records and personal information to remain confidential and to approve their release.

Resident’s representative was not regularly informed of activities related to care or services, including ongoing evaluations, as appropriate to resident’s needs.

Communications from representatives were not answered promptly and appropriately.
INVESTIGATION FINDINGS:
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On 10/12/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20210819100818. LPA Han was properly screen at the front entrance. LPA Han met with the Administrator, Naoko Jones and explained the purpose of the visit.


Regarding the allegation of: Resident was not accorded the right for records and personal information to remain confidential and to approve their release. The Reporting Party explained that the facility consulted and shared confidential health medical records of Resident #1 (R1) and Resident #2 (R2) with another organization without the consent and knowledge of the Responsible Party.

The facility acknowledged the above allegation concerning R1 and R2, however, explained that this organization that the facility has consulted with is part of the facility's management group bound by a Management Agreement. LPA Han reviewed the Management Agreement and it did not revealed that there was an affiliation between the facility and this organization. After the investigation, this allegation is deemed to be substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20210819100818
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: 10/12/2021
NARRATIVE
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Regarding the allegation of: representative was not regularly informed of activities related to care or services, including ongoing evaluations, as appropriate to resident's needs, the facility acknowledged of making arrangements with an outside Consulting Group to conduct an on-site assessment for R1 without notifying the Responsible Party. After the investigation, this allegation is deemed substantiated.

Regarding the allegation of: communications from the representative were not answered promptly and appropriately, the Reporting Party stated that the Responsible Party emailed the facility some questions regarding to R1 and R2 and requested for medical records, and documents but the facility failed to respond to the emails and has yet provided the information.

During the interviews, the facility acknowledged that they failed to provide the entire medical records and documents to the Responsible Party and they failed to respond to some of the email inquires that the Responsible Party has asked for. After investigation, this allegation is deemed substantiated.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20210819100818
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2021
Section Cited
CCR
87506(c)(1)
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RESIDENT RECORDS- (c) All information and records obtained from or regarding residents shall be confidential. (1)The licensee shall be responsible..for safeguarding the confidentiality of their contents.The licensee...shall reveal or make available confidential information only upon the resident's written consent or that of his designated representative.
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The Administrator will review Title 22 , Division 6 Resident Records and submit a statement of acknowledgment after the review. The Administrator will provide in-service to the staff on this regulation.
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This requirement was not met as evidenced by: the facility failed to obtain prior authorization from the Responisble Party for providinng resident's confidential information to an outside organization which posed potential health and safety risks to resident in care.
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The Administrator will submit a copy of the sign-in sheet of the in-service to licensing by the POC due date, 10/26/2021.
Type B
10/26/2021
Section Cited
CCR
87468.1(a)(8)
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PERSONAL RIGHTS OF RESIDENTS....(a)Residents in all residential care facilities....(8)To have their representatives regularly informed...activities related to care or services, including ongoing evaluations, as appropriate to their needs.
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The Administrator will review Title 22 , Division 6 Personal Rights of Residents in All Facilities and submit a statement of acknowledgment after the review.
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This requirement was not met as evidenced by: the facility arranged for an outside consultant group to conduct an on-site assessment for R1 without informing the Responsible party which posed potential health and safety risks to resident in care.
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The Administrator will provide in-service to the staff on this regulation and The Administrator will submit a copy of the sign-in sheet of the in-service to licensing by the POC due date, 10/26/2021
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20210819100818
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/26/2021
Section Cited
CCR
87468.1(a)(9)
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PERSONAL RIGHTS OF RESIDENTS....(a)Residents in all residential care facilities....(9) To have communications to the licensee from their representatives answered promptly and appropriately.
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If the facility has yet provided the medical records and the documents that the RP has requested for from the beginning of July, the facility shall do so by 10/15/2021.
The Administrator will review Title 22 , Division 6 Personal Rights of
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This requirement was not met as evidenced by: the facility failed to provide R1 and R2's complete medical records and documents to the Reporting Party promptly as requested which posed potential health and safety risks to resident in care.
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Residents in All Facilities and submit a statement of acknowledgment after the review. The Administrator will provide in-service to the staff on this regulation and The Administrator will submit a copy of the sign-in sheet of the in-service to licensing by the POC due date, 10/26/2021.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4