385600360-7-5-2023-14-AS-CSMH-CU2T2X-20230724142129

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600360
Report Date: 07/05/2023
Date Signed: 07/05/2023 02:21:06 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
06/16/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230616164015

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: 84	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Care Coordinator, Louie Bautista and administrator, Ana Pacheco		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff handled resident in a rough manner
Staff do not ensure that resident is adequately fed
Food served to resident is cold

INVESTIGATION FINDINGS:

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On 7/5/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230616164015. LPA Han met with care coordinator and administrator and explained the purpose of the visit.

Regarding to allegation of - staff handled resident in a rough manner- there is no additional information forthcoming from the complainant and the co-complainant. However during the initial reporting, the complainant and the co-complainant stated that resident-in-question (R1) experienced aggressive staff who were not gentle during care.

As part of the investigation, LPA reviewed resident records, reviewed facility staff training records, interviewed R1, interviewed administrator and facility staff.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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 4

Control Number 14-AS-20230616164015

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: 07/05/2023

NARRATIVE

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LPA interviewed R1 who described staff roughness and aggression as they failed to listen to R1 when R1 asked them to slow down during care and they did not explain what they were doing resulted R1 feeling unsafe, and uncomfortable. However, R1 reported that improvements were made recently.

LPA interviewed administrator who denied the allegation and stated that he/she met with R1 and R1 did not expressed facility staff was rough and/or was abusive. However, R1 reported that staff did not explain what they were doing during care which resulted R1 feeling scared especially due to R1's poor vision. The administrator also stated that he/she met with R1 and developed a plan to remind staff of R1's health condition and to explain what they were doing while providing care to R1.

LPA interviewed six facility staff who were assigned to R1 on the AM and PM shifts and all of them denied being rough and aggressive towards R1. They stated that R1 would get extremely fearful and scared during care despite their communication while providing care.

LPA interviewed 3 residents and 1 family member and all of them reported that facility staff is respectful, they provided them with the care that they or their loved one required and they have not experienced and/or witnessed staff being aggressive and rough.

During the visit, LPA was provided with 2 copies of R1's needs and services plans; one did not reflect resident's current health condition and the other one did. According to facility director, the needs and services plan that reflects R1's current health condition was updated during LPA's visit and acknowledged that it should have been updated it when the facility was informed in May 2023 by Institute On Aging of R1's change in health condition.

After the investigation, this allegation is deemed to be unsubstantiated as the administrator has already met with R1 and resolved the allegation of staff was rough and aggressive. However, facility failed to update R1's needs and services plan to reflect R1's current health condition, This deficiencies will be cited on LIC809 and LIC809D under Case Management.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20230616164015

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: 07/05/2023

NARRATIVE

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Regarding to the allegation of staff do not ensure that resident is adequately fed, there is no additional information forthcoming from the complainant. However, during the initial reporting, the complainant stated that no one assisted R1 with feeding.

As part of the investigation, LPA interviewed R1, and administrator.

According to R1, facility staff is assisting R1 with feeding now but it was difficult in the past, however, it has been resolved.

LPA interviewed the administrator who denied the allegation and stated that R1 did not required assistance with feeding upon admission. However, R1's vision declined resulted assistance with feeding started a couple of months ago.

LPA interviewed 6 facility staff who were assigned to R1 on the AM or PM shift and all of them reported that they fed R1 during meals. They also reported that on most days, R1's intake was low so they had to go back and forth to encourage R1 to eat more.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to allegation of- food served to resident is cold- there is no additional information forthcoming from the complainant and the co-complainant. However, during the initial report, the complainant stated that no one fed R1 resulted R1 ate cold food.

As part of the investigation, LPA interviewed R1, facility staff, residents and family member.

According to R1, R1 was served cold food but staff warmed it up except for one time.

LPA interviewed facility staff who stated that R1 is a slower eater with poor appetite so they fed R1 at R1's paste. They acknowledged that R1's food would get cold at times but when R1 requested it to be warmed up, they proceeded with that request.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230616164015

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: 07/05/2023

NARRATIVE

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LPA interviewed 3 residents and a family member and all of them stated that they did not have any problems with the temperature of their meals or their loved one's meals. If they wanted it to be warmer, they asked staff to heat it up and they did it.

After 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.

This report is reviewed and discussed with Care Coordinator and administrator. and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

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