385600429-8-10-2022-14-AS-KHOS-CHTJA5-20220831065211

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:14:14 PM

Substantiated

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
05/20/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220520135606

FACILITY NAME:	COVENTRY PLACE		FACILITY NUMBER:	385600429
ADMINISTRATOR:	MARK NITSCHE		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 150	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Acting Administrator, Jeff Sumabat		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not notify resident's responsible party of an incident in a timely manner.

INVESTIGATION FINDINGS:

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On 8/10/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220520135606. LPA Han met with acting administrator, Jeff Sumabat and explained the purpose of the visit.

Regarding to allegation of- staff did not notify resident's responsible party of an incident in a timely manner, the reporting party stated that resident #1 (R1) had a change of condition and resulted R1 transferring to the hospital. However, R1's responsible party was not informed.

As part of the investigation, LPA interviewed the former administrator who acknowledged that the facility failed to notified R1's responsible party when R1 had a change of condition and was hospitalized.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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-20220520135606

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: COVENTRY PLACE	FACILITY NUMBER: 385600429
	VISIT DATE: 08/10/2022

NARRATIVE

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According to the administrator, R1's responsible party was recently changed and it was updated in R1's electronic medical record. However, the facility did not print a copy of R1's updated face sheet for R1's paper chart as staff contacted the old responsible party who was listed in the old face sheet. Therefore, the facility contacted the wrong responsible party. After investigation, this allegation is substantiated. In addition, the facility failed to ensure R1's current record is maintained in R1's paper chart and this finding will be cited on LIC809.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Report was discussed with Administrator, and Appeal Rights provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 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
05/20/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220520135606

FACILITY NAME:	COVENTRY PLACE		FACILITY NUMBER:	385600429
ADMINISTRATOR:	MARK NITSCHE		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS:	DATE:	08/10/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:			TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident suffered a fall resulting in fracture.

INVESTIGATION FINDINGS:

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On 8/10/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220520135606. LPA Han met with the acting administrator and explained the purpose of the visit.

Regarding to allegation of - resident suffered a fall resulting in fracture, as part of the investigation, LPA interviewed resident #1 who stated falling in the bathroom, after the fall, R1 rang the call pendant and staff members immediate answered and provided assistance.

According to R1, staff checked on her regularly such as doing meal times, and when R1 pushed the call pendant for assistance. In addition, R1 stated that there were many facility staff around and they were active. However, R1 also stated that he/she is independent and is able to manage his/her activities of living such as eating, toileting, dressing, etc. Therefore, R1 only used call pendant when R1 needed assistance.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 14-AS-20220520135606

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: COVENTRY PLACE	FACILITY NUMBER: 385600429
	VISIT DATE: 08/10/2022

NARRATIVE

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During the interview with R1, LPA observed R1 was able to move around the apartment independently with a walking device.

Based on the documents provided, R1 is independent with his/her activities of daily living such as grooming, dressing, toileting, mobility/ambulation, transfers, etc.

Based on the interviews, observation, and record review this allegation is deemed unsubstantiated as R1's fall resulting in fracture was an accident and the facility followed their protocols when they discovered R1 was on the floor.

Although the above investigations 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 allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the administrator. A copy is provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 14-AS-20220520135606

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: COVENTRY PLACE	FACILITY NUMBER: 385600429
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/22/2022 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights..(8) To have their representatives regularly informed by the licensee of activities related to care or services...	1 2 3 4 5 6 7	The administrator will provide in-service to staff on the importance of proper notification and will provide a copy of the in-service record to CCL by 8/22/2022.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by resident #1 sustained a change of health condition and the responsible party was not informed by the facility which poses a potential health risk for person in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5