385600360-12-27-2023-14-AS-KHOS-CZAM9C-20240108082428

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600360
Report Date: 12/27/2023
Date Signed: 12/27/2023 11:57:38 AM

Unfounded

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
12/05/2023 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231205160200

FACILITY NAME:	VICTORIAN MANOR		FACILITY NUMBER:	385600360
ADMINISTRATOR:	ANA PACHECO		FACILITY TYPE:	740
ADDRESS:	1444 MCALLISTER STREET		TELEPHONE:	(415) 921-7550
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94115
CAPACITY:	124	CENSUS: 86	DATE:	12/27/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ana Pacheco		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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- Resident sustained injuries in care

- Facility failed to report injuries to responsible party

INVESTIGATION FINDINGS:

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LPA Jeung interviewed staff and obtained additional information from resident's hospice file and facility visitor logs.

Skin discoloration on client's leg was observed by staff on 12/2/23, and also observed by visiting nurse and family member. This was not documented by hospice nurse that day, nor following days.
Assessment by facility LVN and administrator could not be done, as no discoloration or bruise was observed when family member reported bruise on 12/4/23.

Based on investigation by the Community Care Licensing Division of the CA Department of Social Services, these allegations have been determined to be unfounded. This means that the allegations could not have happened and/or are without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2023

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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