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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 11/19/2020
Date Signed: 11/19/2020 05:11:14 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: DATE:
11/19/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:The Executive Director, Mark NitscheTIME COMPLETED:
05:00 PM
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On 11/19/2020, LPA Han and LPA Garcia conducted a Case Management inspection in response to an Unusual Incident that the facility has report. Due to the Pandemic, LPAs are conducting this inspection remotely.

In summary, LPAs interviewed:
1. Resident 1 (R1)
2. The Executive Director

LPAs requested for following documents:

1. R1 Medical Record for the ER visit on 11/9/2020
2. R1 Medical Record for the doctor's visit on 11/9/2020
3. Staff training records on Reporting
4. Executive Director's investigation summary pertaining to the incident
5. Staffing schedule (24 hours) for 11/6/2020,11/7/2020 and 11/8/2020
6. R1's dining schedule for 11/6/20, 11/7/20 and 11/8/20
7. R1's daughter contact information

The Executive Director stated that the above documents will be submitted via email to LPA Han within 24 hours.

LPA emailed the on-line copy of the report to the Executive Director for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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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