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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600270
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:19:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/07/2024 and conducted by Evaluator Dominic Tobola
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241007145518
FACILITY NAME:ALMA VIA OF SAN FRANCISCOFACILITY NUMBER:
385600270
ADMINISTRATOR:CLEITUS JONESFACILITY TYPE:
740
ADDRESS:ONE THOMAS MORE WAYTELEPHONE:
(415) 337-1339
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:175CENSUS: 136DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Cleitus Jones, Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Lack of supervision resulted in resident eloping from facility
INVESTIGATION FINDINGS:
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On 10/15/2024, Licensing Program Analysts (LPA's) Tobola & Jian arrived unannounced for the purpose of initiating complaint investigation and was greeted by Executive Director, Cleitus Jones. LPA toured the facility, interviewed Executive Director, gathered resident records and made observations during the course of the investigation.

Complaint alleges, lack of supervision resulted in resident eloping from facility. Based upon interviews with Executive Director, it was found that resident (R1) had eloped from the facility during the overnight hours of 9/28/2024. It was found that staff (S1) had been asleep during the incident had not properly supervised residents resulting in R1 exiting the facility unsupervised. Upon review of R1's records, it was found that R1 is diagnosed with dementia, has wandering behavior and is not allowed to leave the facility unassisted.

Allegation, Lack of supervision resulted in resident eloping from facility is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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 2
Control Number 14-AS-20241007145518
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALMA VIA OF SAN FRANCISCO
FACILITY NUMBER: 385600270
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/16/2024
Section Cited
CCR
87411(a)
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Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidence by: Administrator failed to prevent resident (R1) from eloping the facility.
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Administrator has implemented corrective actions for staff (S1) leading to termination of position. In addition, Administrator has conducted an in-service training for all staff on elopement procedures and provided copy of training log to CCL. Continuing elopement training will be conducted on a weekly basis
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Based upon interview with Administrator, it was found staff (S1) was asleep during the incident, and not properly supervised resident (R1). Record review shows R1 is diagnosed with dementia, at wander risk and unable to leave the facility unassisted. This serves as an immediate health & and safety risk.
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for an additional month to ensure compliance. Additional care measures for R1 were also implemented to prevent future elopement. Deficiency cleared at the time of visit.
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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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
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