385600235-7-22-2021-14-AS-KHOS-C69KXV-20210826081810

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600235
Report Date: 07/22/2021
Date Signed: 07/22/2021 03:21:10 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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-- Staff failed to address residents change in medical condition.

-- Staff failed to follow proper reporting requirements.

INVESTIGATION FINDINGS:

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

Regarding to staff failed to address residents change in medical condition. According to staff interviews, Staff 1 (S1) stated that resident weights are monitored monthly. Families are informed if a resident has a 5% weight loss within a month.

According to the Mayo Clinic's website, a medical evaluation is called for if a person loses more than 5% of weight in six months to a year, especially for an older adult.

CONTINUE ON NEXT PAGE...

Substantiated

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 facility records, Resident 4 (R4) had a weight of 145lbs on January 2019, 135lbs by October 2019, and was at 129.6lbs by December 2019. R4 had a 15.4lbs or 10.62% weight loss from January 2019 - December 2019. R4's physician was not informed of the weight loss until January 16, 2020 and was not seen by R4's physician until October 26, 2020.

According to administrator, R4 didn't have any hospital visits for 2019.

Regarding to staff failed to follow proper reporting requirements. According to facility records, Resident 1 (R1) had an unwitnessed mechanical fall on May 31, 2018 inside the apartment.
According to staff interviews, S1 stated that incidents, such as resident falls, are reported in writing to Community Care Licensing and to the resident's physician. However, no written report is provided to the person responsible for the resident, only verbal report is given according to S1.

The allegations were SUBSTANTIATED, meaning that the allegation was valid because the preponderance of evidence standard has been met.

This report was reviewed and discussed with the Executive Director and a copy is provided.

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)

Page: 3 of 3

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/22/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/05/2021 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care... (1) The licensee shall arrange, or assist in arranging, for medical... care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Administrator shall ensure to provide an in-service training to facility staff that will suffice the requirements of Section 87465 Incidental Medical and Dental Care. And provide proof of training, with
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on staff interviews and record reviews, the licensee failed to arrange for medical care appropriate to R4's conditions and needs which poses potential health risks to residents in care.	8 9 10 11 12 13 14	staff signatures, to the San Bruno licensing by the POC due date, 8/5/2021
Request Denied Type B 08/05/2021 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirement... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of... (D) Any incident which threatens the welfare, safety or health of any resident.	1 2 3 4 5 6 7	Administrator shall ensure to provide an in-service training to facility staff that will suffice the requirements of Section 87211 Reporting Requirement. And provide proof of training, with
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on staff interviews, the licensee failed to ensure that written reports are submitted to the person responsible for the resident within seven days of the occurrence which poses potential health and safety risks to residents in care.	8 9 10 11 12 13 14	staff signatures, to the San Bruno licensing by the POC due date, 8/5/2021..

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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2021

LIC9099 (FAS) - (06/04)

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