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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 05/03/2023
Date Signed: 05/03/2023 11:22:41 AM


Document Has Been Signed on 05/03/2023 11:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CATHEDRAL HILLFACILITY NUMBER:
385600429
ADMINISTRATOR:JEFF SUMABATFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 97DATE:
05/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Memory Care Director, Joy Quilet TIME COMPLETED:
11:30 AM
NARRATIVE
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On 5/3/2023, Licensing Program Analyst (LPA) Murial Han conducted a case management visit to deliver the findings of a case management visit that was conducted on 4/25/2023. LPA Han met with memory care director and explained the purpose of the visit.

On 4/12/2023, facility report an abuse allegation that staff #1 (S1) witnessed staff #2 (S2) of blocking resident #1 (R1) from leaving one of the pods and punching R1's abdominal area with small pink dumbbells. S1 reported that this incident happened on 4/4/2023 but S1 did not reported it to the facility director until 4/12/2023.

When the facility director was notified of the incident, the facility took actions to ensure R1's safety, however, due to the late reporting from S1, the facility director acknowledged that the alleged abuser was assigned to care for R1 one more time before he/she was placed on administrative leave.

In addition, based on S1's training records from 11/13/2022, it did not indicated that S1 received training on Abuse and Neglect and the facility director was not able to provide additional training records beyond 11/13/2022.

Based on the complaint investigation, the facility did not ensure R1's safety as S1 did not report the incident until 8 days later and facility did not ensure S1 received required training.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with memory care director.

A copy of this report and the Appeal Rights is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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Document Has Been Signed on 05/03/2023 11:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 CATHEDRAL HILL
FACILITY NUMBER: 385600429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited

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87468.1 Personal 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/Licensee will develop a plan to ensure abuse allegation is reported immediately and the plan needs to include staff training.
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This requirement is not met as evidenced by S1 witnessed an abuse allegation but S1 did not report it to facility director until 8 days later resulted the alleged abuser was assigned to care for R1 one more time before he/she was placed on administrative leave which posed an immediate health risk to resident in care.
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The administrator/licensee will submit a copy of the plan to CCL by 5/4/2023.
Type B
05/10/2023
Section Cited

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87411 Personnel Requirements - General..(c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training..(3) The training shall include, but not be limited to, the following:..(C) Residents rights,..
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The administrator/licensee will conduct audits of staff training records ensuring facility staff is in compliance with their required training.
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This requirement is not met as evidenced by based on the training records provided by the facility for S1, it does not indicate that S1 has recevided the above training which posed a potential risk for residents in care.
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The administrator/licensee will provide a copy of the audit result and if staff is identified not having required training completed, the administrator will submit a copy of the plan to complete the training for all staff. These documents will be submitted to CCL by 5/10/2023.
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: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
LIC809 (FAS) - (06/04)
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