385600360-1-27-2023-14-AS-CSMH-CNM35P-20230131165700

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600360
Report Date: 01/27/2023
Date Signed: 01/27/2023 12:48:25 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
09/26/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220926122653

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: 75	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator, Ana Pacheco		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff did not properly address resident being burned by another resident
Facility staff are not meeting toileting needs of resident
Facility lacks adequate staffing to meet residents care needs

INVESTIGATION FINDINGS:

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On 1/27/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220926122653. LPA Han met with administrator and explained the purpose of the visit.

Regarding to allegation of- staff did not properly address resident being burned by another resident, there was no additional details forthcoming from the reporting party, however, during the initial reporting, the reporting party stated that resident #1 (R1) was severely burned by another resident.

The administrator denied the above allegation and stated that when the administrator was informed of such incident, the administrator instructed resident care coordinator to assess R1. The resident care coordinator and another staff went to R1's room and R1 was combative and agitated and refused to be assessed, however, R1 reported that the incident as another resident (R2) followed R1 into R1's room, touched R1's belongings and when R1 asked R2 to stop, R2 grabbed the hot water that R1 was holding and threw it on R1.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

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 5

Control Number 14-AS-20220926122653

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: VICTORIAN MANOR	FACILITY NUMBER: 385600360
	VISIT DATE: 01/27/2023

NARRATIVE

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As part of the reporting requirement, the facility reported it to R1's physician , Long Term Care Ombudsman and R1's responsible party; subsequently, R1 was seen by R1's physician on the following day. The facility also attempted to collect more details from staff, but none of them had knowledge of such incident as it was witnessed.

As prevention, facility offered R1 to move to another room on a different floor but R1 did not accept the offer. However, the facility was able to move R2 after a discussion with the responsible party. Since the room transfer, there was no further incidences.

Based on the documents provided by the facility, LPA observed this incident was reported on 11/20/2020 (incident happened on 11/19/2020) via LIC 624 (Unusual Incident/Injury Report) indicating that it was reported to R1's responsible party, Long Term Care Ombudsman and R1 was seen by On-Lok Clinic. In addition, a SOC 341 ( Report of Suspected Dependent Adult/Elder Abuse) was also completed.

Based on interviews, and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated.

Regarding to allegation of- facility staff are not meeting toileting needs of resident and facility lacks adequate staffing to meet resident's care needs, there is not additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that facility staff failed to change R1's soiled diaper and asked R1 to poop in R1's diaper.

As part of the investigation, LPA interviewed R1 who stated that it took the staff hours to change R1's soiled diaper.

The administrator and the resident care coordinator denied the above allegation and stated that every morning before night shift staff ends their shift at 6:30am, they would clean, change, provide a bed bath and get R1 into a wheelchair to start R1's day. In addition, they have not heard any complaints from R1, the responsible party and the physician regarding this allegation. Furthermore, the administrator stated that the facility recently added additional staff to anticipate new residents from Laguna Honda.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 14-AS-20220926122653

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: VICTORIAN MANOR	FACILITY NUMBER: 385600360
	VISIT DATE: 01/27/2023

NARRATIVE

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LPA interviewed staff #1 (S1) who stated that night shift staff would clean, change and get R1 ready for the day and when S1 arrived at work, R1 was already cleaned and up in a wheelchair. S1 was not aware of such allegation. In addition, S1 stated that staff assisted R1 to the toilet during the day and R1 performed self-care after toileting unless R1 requested for assistance.

LPA interviewed 3 other residents regarding to the care that they received by staff including but not limiting to toileting needs and all of them reported that they were satisfied with the care that they received and staff was attentive to their needs.

During the initial visit, LPA observed residents to be cleaned, comfortable and LPA did not smell any unpleasant odor at the facility.

Based on observation and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated.

Although the above allegations 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 allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
09/26/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220926122653

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:	DATE:	01/27/2023
		UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Administrator, Ana Pacheco		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not providing medication as prescribed to resident
Facility staff are retaliating against the resident for filing a complaint
Staff did not prevent another resident from entering resident's room
Staff does not treat resident with respect

INVESTIGATION FINDINGS:

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On 1/27/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220926122653. LPA Han met with administrator and explained the purpose of the visit.

Regarding to allegation of facility is not providing medication as prescribed to resident- there is no additional information forthcoming from the reporting party, however, the reporting party stated during the initial reporting that facility did not give resident #1 (R1)'s prescribed medication.

The administrator denied the allegation and stated that R1 was under the impression that the there was a prescribed medication for 7 days, however, the physician's order was for 5 days but no one clarified it with R1. Therefore, R1 assumed that the facility did not administered the full course of the medication. In addition, the administrator stated that when the administrator was informed of R1's concern, the administrator explained to R1 of the physician's order for such medication and encouraged R1 to speak to R1's physician and R1 was satisfied with the explanation.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 14-AS-20220926122653

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: VICTORIAN MANOR	FACILITY NUMBER: 385600360
	VISIT DATE: 01/27/2023

NARRATIVE

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LPA observed R1's medication administration record that indicated this specific medication was ordered for 5 days and 4x daily and the medication administration record indicated that it was properly administered by facility staff.

Based on record review, and interviews during the course of the investigation, this allegation is deemed to be unfounded.

Regrading to allegation of facility staff are retaliating against the resident for filing a complaint- there is no additional information forthcoming from the reporting party and R1.

As part of the investigation, LPA interviewed the administrator who denied the allegation and stated that facility encouraged residents and their responsible parties to contact the advocates such as the Long Term Care Ombudsman and the Long Term Care Ombudsman information is posted in the facility.

Therefore, this allegation is deemed to be unfounded as there is no details provided.
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Regarding to staff did not prevent another resident from entering resident's room- there is no additional information forthcoming from the reporting party.

The administrator denied the allegation and stated that this incident was not witnessed by facility staff and if it was, staff would have discouraged R2 from entering R1's room.

LPA interviewed R1 who stated that when R2 followed R1 into R1's room, there was no staff around to stop R2 from doing that.

Based on interviews during the course of the investigation, this allegation is deemed to be unfounded.

Regarding to allegation of- staff does not treat resident with respect, there is no additional information forthcoming from the reporting party.

As part of the investigation, LPA interviewed other residents who stated that facility staff is attentive, they treat residents with respect and dignity.

Based on interviews during the course of the investigation, this allegation is deemed to be unfounded.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2023

LIC9099 (FAS) - (06/04)

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