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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600270
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:59:47 PM


Document Has Been Signed on 09/20/2024 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 FRANCISCOFACILITY NUMBER:
385600270
ADMINISTRATOR:CLEITUS JONESFACILITY TYPE:
740
ADDRESS:ONE THOMAS MORE WAYTELEPHONE:
(415) 337-1339
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:175CENSUS: 134DATE:
09/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Cleitus Jones, Executive DirectorTIME COMPLETED:
04:15 PM
NARRATIVE
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On 9/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following with case management regarding complaint investigation and incident involving resident (R1) and was greeted by Executive Director, Cleitus Jones. On 8/22/2024, R1 had been assisted onto the facility van for an appointment by staff (S1). It was found that the facility van wheelchair lift was not in proper electronic functioning order but is also equipped with a manual hand crank lever located inside the vehicle, that still provides lifting function in case of electronic failure. S1 stated that they assist residents into the wheelchair lift based on transportation practices for wheelchair assistance by placing residents facing forwards and outside the vehicle. During the event, S1 had properly loaded R1, facing forwards towards the outside of the vehicle while S1 had operated the manual lift from the inside of the vehicle. During the lifting process it was identified that R1 had sustained minor injury from falling forward from the wheelchair but not due to intent or neglect. During LPA observation of wheelchair lift, it appeared that the manual crank causes a jerking motion which was a potential factor in R1 moving forward and sustaining a fall from the lift with minor injury

Based on interviews with staff, R1 was not equipped with a standard wheelchair device with larger rear wheels but instead equipped with a foldable wheelchair with a set of smaller swiveling wheels, with less or no leverage towards the back of the wheelchair. Although not due to intent or neglect, staff did not ensure that R1 was provided safe accommodations and equipment or additional support to prevent R1 from sustained injury.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2024 03:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87468.1(a)(2)

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To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidence by: Based upon interviews with Executive Director, staff (S1), review of facility records and LPA observation, facility failed to ensure resident has safe accommodations
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Facility agrees to provide written statement of how they will remain in compliance regarding residents being accorded safe accommodations and equipment involving facility vehicles by POC date 9/27/2024.
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and equipment as resident (R1) sustained injury from falling off wheelchair lift during transport. This serves as a potential health & safety & personal rights risk to residents in care.
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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: 09/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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