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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600235
Report Date: 04/07/2023
Date Signed: 04/07/2023 04:38:54 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
07/27/2020 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200727150444
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: 47DATE:
04/07/2023
UNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Sakae HamiltonTIME COMPLETED:
04:45 PM
ALLEGATION(S):
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9
- Resident sustained a fracture while in care
- Staff do not provide activities for residents
- Staff do not ensure residents are adequately fed

INVESTIGATION FINDINGS:
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Based on observations made during initial complaint visit on 8/4/20, interviews with clients' responsible parties and staff, and review of documents provided by facility--including Incident Reports submitted to CCLD--these allegations are determined to be unsubstantiated.

Unusual incidents--medical emergencies including falls--were reported to CCLD via submission of Incident Reports. In early 2020, due to absence of full-time activity director and COVID pandemic--which eliminated group activities--facility activities were greatly curtailed. Individualized social visits were facilitated by staff to engage residents and monitor them until group activities resumed in Fall of 2020.
Food supplies were observed to be adequate during inspection in August 2020 and food service is overseen by food and beverage director, who is a certified registered dietician. In addition to meals, snacks were delivered to rooms by staff. Clients were assisted to eat by caregivers, who report to director of resident care when there are changes in appetite.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2023
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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