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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 11/02/2022
Date Signed: 11/02/2022 01:55:54 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
09/02/2022 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220902080236
FACILITY NAME:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:JEFF SUMABATFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 144DATE:
11/02/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Melon RiveraTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Insufficient staffing to meet residents' needs
Facility is unkempt
Facility staff failed to provide a safe and comfortable environment for residents
INVESTIGATION FINDINGS:
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On 11/2/2022 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220902080236. LPA Han met with the administrator and explained the purpose of the visit.

Regarding to allegations of insufficient staffing to meet residents' needs, the reporting party stated that the concern is for the memory care unit. The memory care unit consists of 5 different pods and the facility used to assign one staff for each pod, however, this practice has stopped recently. Therefore, during their visit, they have witnessed and experienced the level of care that the resident received has deteriorated and the overall cleanliness of the facility has gone down as well.

During the investigation, LPA interviewed staff #1 (S1) who stated that there are many uncovered open shifts and they are working a lot of overtime to cover it and the facility is getting staff from the agency but they are still short.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
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-20220902080236
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: 11/02/2022
NARRATIVE
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Based on the memory care staff assignment sheet, there are 5 slots for 5 facility staff on am and pm shifts and 4 slots for 4 facility staff on the night shift. LPA reviewed the assignments from 8/3/2022 - 8/14/2022 and observed multiple open shifts, multiple staff names were crossed out due to no shows, and staff working double shifts to cover for open shifts. After the investigation, this allegation is substantiated.

Regarding to the allegations of facility is unkempt, according to the reporting party, during their visits of resident #1 (R1) who resided in the memory care unit, they witnessed R1's room was dirty, feces around the toilet seat, dirty adult brief on the bedside table, and dirty clothes on the floor that should have been brought to the laundry by staff.

As part of the investigation, on 9/7/2022, LPA toured the memory care unit with the facility director and made the following observations:

At 11:10am, LPA and the director went into room 110, and observed resident in bed, there was as a dried brown stain on the coach, there were white particles on the floor by the head of the bed, there was dirty clothes on the floor by the kitchen. According to the staff #2 (S2), the room has not been cleaned by the housekeeper.

At 11:23 am, LPA and the director went into room 118 and observed resident in bed, a pair of shoes and 2 pairs of wheelchair footrests placed on top of 2 chairs. According to staff #3(S3), the room has not been cleaned by the housekeeper.

At 11:40 am, LPA and the director went into room 120 and met with resident #2( R2) who stated that the room has not been cleaned and it has not been cleaned as often as it should be. LPA and the director observed dried brown/black spots inside the toilet bowl, dry crumbs on the floor and rusty/dusty fan. According to the director, this room should have been cleaned already but he/she was not sure if it was actually cleaned as the assigned housekeeper called in sick and the director did not know which staff was replacing the sick call.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20220902080236
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: 11/02/2022
NARRATIVE
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LPA interviewed 5 housekeeping and maintenance staff who were on duty on 9/7/2022 and all of them reported that they did not clean the memory care unit on that day as they were not assigned to it. After the investigation, this allegation is substantiated.

Regarding to the allegation of facility staff failed to provide a safe and comfortable environment for resident, due to the above findings, this allegation is substantiated as the facility was found to be unkempt, uncleaned, unsanitized, and uncomfortable for residents. After the investigation, this allegation is substantiated.

Based on interviews, observations and record review 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. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator, a copy is provided and Appeal Rights provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20220902080236
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: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/04/2022
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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The administrator/Licensee will develop a plan to ensure the facility has sufficient interdisciplinary staff members on all shifts to care for residents in need. The administrator / licensee will provide a copy of
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based on document provided, facility's care staff assignments revealed multiple open shifts and on 9/72022, there was no housekeeping staff assigned in the memory care unit which posed an immediately health risk for residents in care.
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the plan to CCL by the plan of correction due date of 11/4/2022.
Type B
11/15/2022
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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The administrator and/or designee will develop a plan to monitor and to validate that resident's rooms and the overall environment is cleaned, sanitized and tidy on a daily basis.
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This requirement is not met as evidence by: during the facility tour in the memory care unit that was provided by one of the director, LPA observed several rooms were not cleaned which poses a potential health risks for residents in care,
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The administrator will submit a copy of such plan to CCL by 11/14/2022.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20220902080236
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: 11/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited
CCR
87468.1(a)(2)
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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:(2) To be accorded safe,....
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The administrator will develop a plan to ensure residents and their family members feel the facility is providing a safe, cleaned and sanitized environment on a daily basis. The administrator will provide
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The requirement is not met as evidenced by: the facility failed to have sufficient number of personnel at all times to ensure residents to be accorded safe, healthful and comfortable which poses a potential health risk for residents in care.

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in-services to staff on such plan and will submit a copy of this plan along with a copy of the in-service sign-in records to CCL by 11/14/2022.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5