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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 09/25/2020
Date Signed: 09/29/2020 05:04:29 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:MARK NITSCHEFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 144DATE:
09/25/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Michelle BertschTIME COMPLETED:
10:00 AM
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On 09/25/2020, Licensed Program Analyst (LPA) Shabana Buksh, conducted a video tele - case management inspection with Nurse, Michelle Bertsch. This inspection was in regards to an incident that occurred on 09/16/2020 with Resident (R1) and nurse (S1), and witnessed by nurse (S2). Administrator and S2 were interviewed regarding the incident. LPA met and spoke to R1 on Facetime. LPA requested pertinent documents and training of nurse from facility. LPA ensured with Executive Director that S1 would not be working with residents until investigation is complete.

Report was emailed to Executive Director, Mark Nitshce for review and signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 09/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2020
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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