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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 02/21/2023
Date Signed: 02/21/2023 12:06:47 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
10/24/2022 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20221024090920
FACILITY NAME:IVY PARK AT CATHDERAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR:MELON RIVERAFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 119DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Carol DowellTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Staff are mismanaging resident's medications.
INVESTIGATION FINDINGS:
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On 2/21/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221024090920 LPA Han met with the administrator and explained the purpose of the visit.

Regarding to allegation of staff are mismanaging resident's medications- the reporting party stated that facility failed to administered 2 of resident #1 (R1)'s medications- medication #1 for 8 days and medication #2 for 2-3 days due to lack of medications as the facility staff did not properly follow through with the pharmacy and the physician for the refills. In addition, the reporting party stated that this matter was discovered by a former staff days later and he/she took actions by contacting the pharmacy and physician and the medications were delivered in 2 days with one of the two medications being on a higher dosage.

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: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
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 6
Control Number 14-AS-20221024090920
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: IVY PARK AT CATHDERAL HILL
FACILITY NUMBER: 385600429
VISIT DATE: 02/21/2023
NARRATIVE
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As part of the investigation, LPA interviewed former administrator, facility staff, and reviewed documentation.

According to the former administrator, the medications were not administered to R1 because medications were not delivered by the pharmacy.

According to staff #1 (S1), the refills for the medications were sent to the pharmacy 2 days prior to running out but the medications were not delivered on time. Therefore S1 followed up with the pharmacy on 10/10/2022 and S1 was told that there was no refills and in order for the medication to be delivered, they needed a new physician's order for the refill. Therefore, on the same day, S1 faxed an order to R1's physician requesting a refill. S1 stated that S1 continued to follow-up on R1's medications as they were not delivered but S1 did not remember if the interactions were documented.

In addition, S1 stated that this matter was discovered by a former staff on 10/17/2022, and this former staff acted on it and the medications were delivered within 2 days.

According to staff #2 (S2) , the medication was not administered as the facility was waiting for the physician to approve the refill and S2 did not follow-up with the physician and the pharmacy while waiting for the medications.

According to staff #3 (S3), the medication was not administered as the medication was not available and S3 can't not remember if S3 followed up while waiting for the medications.

Based on R1's electronic medication administration records, medication #1 from 10/10/2022 5:00PM to 10/18/2022 8AM are initialed and circled and medication #2 from 10/16/2022 5:00PM - 10/18/2022 5PM are also initialed and circled. According to former administrator, circles around facility staff initials is an indication that the medications were not given on those days and times.

SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 14-AS-20221024090920
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: IVY PARK AT CATHDERAL HILL
FACILITY NUMBER: 385600429
VISIT DATE: 02/21/2023
NARRATIVE
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In addition, the electronic medication administration records revealed that the reasons the medications were not administered on the above dates and times were due no refills, waiting for refills, and waiting for medication; the facility was not able to provide additional documentation indicating follow-up attempts made by facility staff until a note from a former staff on 10/17/2022 at 11:30am indicating that this matter was discovered by this former staff on 10/17/2022 and this staff took necessary actions to resolve the matter. The medication arrived on 10/20/2022 and it was administered to R1 with one of the medication being a higher dosage.

Based on record reviews, and interviews during the course of the investigation, this allegation is deemed to be substantiated as the facility was not able to provide proof that facility staff followed up on R1's medication from 10/11/2022 - 10/16/2022, which resulted in delaying of medications being delivered and administered.

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: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20221024090920
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: IVY PARK AT CATHDERAL HILL
FACILITY NUMBER: 385600429
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/21/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall..(2) To be accorded safe, healthful ... This requirement is not met as evidenced by facility staff failed
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Licensee shall develop a plan of action in writing describing how the facility shall ensure proper follow through from facility staff on resident's medication refills and document accordingly. Plan of correction to include plan to train staff.
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to follow through with R1's pharmacy and R1's physician on 2 prescribed medications which resulted a longer delay of medication not being administered to R1 as prescribed which poses a potential health risk for residents in care.
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License will provide a copy of the plan and a copy of the education record by 2/22/2023.
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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: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
10/24/2022 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20221024090920

FACILITY NAME:IVY PARK AT CATHDERAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR:MELON RIVERAFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: DATE:
02/21/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Carol DowellTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff are not properly trained.
INVESTIGATION FINDINGS:
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On 2/21/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221024090920 LPA Han met with the administrator and explained the purpose of the visit.

Regarding to allegation of staff are not properly trained- the reporting party stated resident #1 (R1) was not given 2 of the prescribed medications due to lack of refills and facility staff did not follow through which resulted R1 not getting the medications as prescribed.

As part of the investigation, LPA interviewed the former administrator, facility staff and reviewed records.

The former administrator denied the allegation and stated that facility staff who assists residents with self-administration of medication are educated and trained.

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: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20221024090920
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: IVY PARK AT CATHDERAL HILL
FACILITY NUMBER: 385600429
VISIT DATE: 02/21/2023
NARRATIVE
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LPA interviewed 4 facility staff who assists residents with self-administration of medication and all of them were able to articulate the procedures when a prescribed medication is available for administration.

Facility provided a staff sign-in record of a recent in-service that was conducted on 10/27/2022 by the directors on medication related topics.

Based on interviews, observations and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated as the facility was able to articulate the proper procedures when the medication is not delivered by the pharmacy on time. However, the facility staff failed to follow up on the procedures as they described which resulted a longer delay of the medications being available for R1 and this finding is cited on LIC 9099 and LIC 9099D.

This report is reviewed and 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: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6