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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 01:58:30 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
08/31/2022 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220831083525
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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Staff did not respond in a timely manner to resident's call for assistance after resident was injured
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-20220831083525. LPA Han met with the administrator and explained the purpose of the visit.

Regarding allegation of staff did not respond in timely manner to resident's call for assistance after resident was injured, according to the reporting party, resident #1 (R1) fell at 1AM, R1 pressed the call pendant for assistance and facility staff did not respond to R1's call until 3AM.

As part of the investigation, LPA Han interviewed R1 who stated that after the fall, R1 pressed the call pendant for help, then R1 looked at the alarm clock that was on the night stand next to the bed which revealed 1AM then R1 fell asleep on the floor while waiting for help and when facility staff answered R1's call, R1 looked at the alarm clock again and it was passed 3AM.

LPA interviewed staff #1(S1) concerning to facility's call light monitoring system and S1 stated that the call light response time is being monitored by the receptionist at the front desk.
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-20220831083525
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 staff #2(S2) to obtain additional details on the call light monitoring system. According to S2, the front desk has a monitor that shows residents who called for assistance and the time they pressed their call pendant. When a call is not being answered after 15 minutes, the system would provide a signal which triggered the receptionist to call the caregiver(s) to answer that call. However, currently the night shift is not being monitored as the facility used to have a receptionist 24 hours a day but recently the pm shift staff left and the night shift staff took over that position which left an open position on the night shift, Therefore, there is no receptionist monitoring the call light response time on the night shift.

Based on staff documentation of the fall, on 7/14/22, R1 had an witnessed fall at 3:10am and according to R1, that was the time when staff responded to R1's call pendant but the fall happened at 1am.

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: 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-20220831083525
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
87564(f)(1)
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87464 Basic Services(f)Basic services shall at a minimum include: (1) Care and supervision

This requirement is not met as evidenced by:
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The administrator/licensee will submit a plan that includes: 1. facility's system to ensure resident's call light response time is being monitored 24 hours a day; 2. to ensure residents are
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R1 fell at 1am, R1 pressed the call pendant for assistance and facility staff did not answer R1's call until 3 am which posed an immediately health risk for residents in care.
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satisfied with the call light response time.
The administrator will provide in-service(s) to staff on such plan and provide a copy of such plan and a copy of the in-service sign-in records to CCL by the plan of correction due date of 11/4/2022.
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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: 3 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
08/31/2022 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220831083525

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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Staff did not seek medical attention for resident in a timely manner
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-20220831083525. LPA Han met with the administrator and explained the purpose of the visit.

Regarding to allegation of staff did not seek medical attention for resident in a timely manner, the reporting party stated that after resident #1 (R1)'s fall, staff informed the responsible party that R1 was fine and did not need to go to the hospital. However, the responsible party visited R1 2 days after the fall and injuries were noted.

As part of the investigation, LPA interviewed R1 who stated that after the fall, staff assessed R1 and noted some injuries and they asked if R1 wanted to go to the hospital, however, R1 declined it as R1 did not think the injuries warranted a hospital visit.
Unsubstantiated
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: 4 of 5
Control Number 14-AS-20220831083525
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 documents provided, staff noted that R1 sustained some injuries on R1's left hand due to the fall. Although staff did not document that R1 did not want to go to the hospital after the fall, however, R1 reported to LPA during the interview that staff offered to call an ambulance but R1 declined it.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

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 discussed with the administrator.

A copy is 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: 5 of 5