385600360-2-14-2024-14-AS-KHOS-D3GG89-20240318050642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600360
Report Date: 02/14/2024
Date Signed: 02/14/2024 10:45:16 AM

Unsubstantiated

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
07/14/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230714142111

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: 83	DATE:	02/14/2024
		UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Administrator - Ana Pacheco		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

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- Staff are minsmanagaing resident's medication
- Staff refused to provide resident's authorized representative with menus
- Staff are not meeting resident's needs

INVESTIGATION FINDINGS:

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On --/--/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations received. LPA met with administrator Ana Pacheco and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews, made observations, and reviewed documents related to the complaint. It is discovered that R1 had conditions that caused R1 to be hosptialized frequently. The facility did attempt to meet the needs of R1, but the needs of R1 began to take a toll on staffing and the abilities of the facility to meet the resident's needs, due to the frequent hospitalization. The resident had frequent medication changes due to R1's mental condition that would fluctuate almost daily and dietary modifications due to kidney condition.

Continued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/14/2024

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-20230714142111

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: VICTORIAN MANOR	FACILITY NUMBER: 385600360
	VISIT DATE: 02/14/2024

NARRATIVE

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LIC9099 - Page 2

In regards to medications being mismanaged, LPA reviewed the medication administration record (MAR) for R1 and it does show on the MAR that the resident did receive the questioned medication. Per interview with facility staff, the medication was a 30 day supply and they were using such supply before picking up the refill of the medication. Due to R1 being hospitalized for several days at a time, the medication went unused at the facility, so the facility had the excess supply they were using until needing to be refilled. In regards to facility menus, the facility does have menus posted for residents in the facility. Menus are posted for weekly meals. If a resident does have a prescribed diet, or modified diet, the facility will abide by such recommendations made by a physician. The facility does not have a dietician on staff to assess and provided each resident a personal diet plan. The facility does follow USDA standards and diabetic diets if needed. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed administrator. Copy is provided on this day.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 02/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2024

LIC9099 (FAS) - (06/04)

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