385600270-9-22-2022-14-AS-KHOS-CKHNU5-20221024104546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600270
Report Date: 09/22/2022
Date Signed: 09/22/2022 01:55:29 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
04/20/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220420125337

FACILITY NAME:	ALMA VIA OF SAN FRANCISCO		FACILITY NUMBER:	385600270
ADMINISTRATOR:	ALAN FOX		FACILITY TYPE:	740
ADDRESS:	ONE THOMAS MORE WAY		TELEPHONE:	(415) 337-1339
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94132
CAPACITY:	175	CENSUS: 116	DATE:	09/22/2022
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Administrator, Alan Fox		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident sustained a stage 3 pressure ulcer while in care

INVESTIGATION FINDINGS:

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On 9/22/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220420125337. LPA met with the administrator and explained the purpose to today's visit.

Regarding to allegation of- resident sustained a stage 3 pressure ulcer while in care, there is no additional information provided by the reporting party.

During the course of the investigation, LPA interviewed facility staff and they stated that resident #1 (R1) has a chronic skin condition, and R1's physician prescribed a topical cream for R1 as a protection for incontinence. In addition, it was documented by the home health nurse that R1 is at high risk for pressure ulcers.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

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-20220420125337

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ALMA VIA OF SAN FRANCISCO	FACILITY NUMBER: 385600270
	VISIT DATE: 09/22/2022

NARRATIVE

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According to staff, to alleviate pressure in bed and prevent R1 from developing pressure ulcers, facility requested a hospital bed with pressure relieving mattress, staff turned and repositioned R1 every 2 hours and provided incontinence care every 2 hours to ensure R1 was cleaned and dry.

Based on documents provided by the facility, on 3/5/2022, facility staff noted R1 developed a pressure ulcer. The facility staff completed a change of condition and notified R1's physician. While waiting for the physician to respond, facility provided treatment to R1's wound. Subsequently, R1's physician ordered a home health referral for wound evaluation and management. In addition, facility conducted a virtual appointment with R1's physician and R1's responsible party concerning the pressure ulcer.

On 4/18/2022, R1's wound was noted to be stage 3 by the home health nurse and R1 was transferred to the hospital on the next day for worsening of the wound.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated as the facility provided actions to prevent R1 from getting pressure ulcers but due to R1's health condition, R1 developed pressure ulcer and when it was noted by the facility, the facility took actions.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is discussed and reviewed with the administrator.

A copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2022

LIC9099 (FAS) - (06/04)

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