385600429-4-24-2023-14-AS-KHOS-CRFJ3T-20230502064203

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 04/24/2023
Date Signed: 04/24/2023 01:53:55 PM

Unsubstantiated

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
07/01/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220701103915

FACILITY NAME:	COVENTRY PLACE		FACILITY NUMBER:	385600429
ADMINISTRATOR:	LIBHART, JILL C.		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 67	DATE:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Business Office Director, Gianni Amari		TIME COMPLETED:	02:05 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Staff are not following resident's care plan.
Staff are not meeting resident's showering needs.
Staff do not assist resident with feeding.
Facility does not provide a food menu to residents.
Staff do not provide adequate laundry service.
Resident's call button is not being answered in a timely manner.
Authorized representative is not provided resident records in a timely manner.
Staff speak to residents in an inappropriate manner.
Staff are mismanaging resident's medications.
Staff are not properly trained.
Staff do not safe guard resident's personal items

INVESTIGATION FINDINGS:

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On 4/24/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220701103915. LPA Han met with business office director, and explained the purpose of the visit.

Regarding to allegation of resident sustained unexplained injuries while in care, the reporting party stated that R1's responsible party noted a large bruise and skin tear on R1's forearm.

As part of the investigation, LPA interviewed facility staff and reviewed documents.

According to facility staff, the responsible party did not report to them that R1 had a large bruise and skin tear on the forearm. However, during R1's stay, R1 was transferred to the hospital multiple times due to crying, hitting staff, and staff did not know what R1 wanted, therefore, they transferred R1 to the hospital.

In addition, staff reported that there was one incident where R1 was screaming, crying, falling back on staff, repeated refusal for personal hygiene and combative throughout the shift so the facility transferred R1 to the hospital for further evaluation.

Based on the documents provided, LPA observed R1 had a few changes of condition during R1's stay that resulted in hospital transfers but no indication of a large bruise and skin tear.

After the investigation, this allegation is deemed to be unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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-20220701103915

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: 04/24/2023

NARRATIVE

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Regarding to the allegation of staff are not following resident's care plan- the reporting party stated this allegation is related to the other allegations such as resident #1 (R1) was only given shower once within the 6 months, R1 was not assisted with feeding and assisting with cutting the foods and R1 was not provided with food menu, and staff was not assisting R1 and resident #2 (R2)'s laundry services.

As part of the investigation, LPA reviewed documents, interviewed facility staff and responsible party of the residents.

Regarding to showering needs, LPA observed facility's shower schedule and it indicated both R1 and R2 were scheduled to be showered 2x/week on the AM shift.

LPA interviewed 4 facility staff, and all of them reported that they assisted R1 and R2 with their showers but there were times when R1 did not want a shower, however, they still encouraged R1 to take a shower and sometimes R1 complied and sometimes R1 refused.

LPA interviewed responsible party of other residents and all of them reported that facility staff assisted their loved ones with showers several times a week and/or daily. One of them confirmed that when residents did not want a shower, facility staff continued to encourage them to do so. After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to the allegations of- staff did not assist resident with feeding and did not provide alternative menu to residents when residents disliked the meal that was served.

Facility staff denied the allegations and stated that they assisted R1 and R2 during meals unless the meals were brought in by the responsible party. The facility staff also remembered R1 and R2's food preferences as they assisted them with meals.

LPA interviewed responsible party of other residents and all of them reported that facility staff assisted their loved ones with their meals including but not limiting to escorting them to the dining room, setting up their meals, cutting up their foods, and offering food alternatives if their loved ones did not like the food that was served.

Based on documents provided, it indicated that facility was offering alternative food items.

After the investigation, this allegation is deemed to be unsubstantiated.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 14-AS-20220701103915

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: 04/24/2023

NARRATIVE

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Regarding to allegation of- staff do not provided adequate laundry services, the reporting party stated that facility staff got other resident's clothes for R1 and R2 from the laundry and R1 and R2 were missing clothes after being washed.

LPA interviewed staff members who stated that R1 and R2 resided at the facility for a few months and during their stay, their responsible party was doing their laundry and brought it back to the facility.

LPA interviewed responsible party of the other residents and all of them reported that they did not have any concerns with facility's laundry services. One of them reported that there were a few times that they discovered some clothes that did not belong to their loved ones but they reported it to staff and it was handled right away.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to allegation of- resident's call button is not being answered in a timely manner, the reporting party stated that it took the facility staff 1-3 hours to answer call button during the evening and night shift.

LPA interviewed the former administrator who denied the allegation and stated that it may take a little longer for facility staff to answer call button at certain times throughout the shift such as meal times and/or if they were assisting other residents but not 1-3 hours.

LPA interviewed facility staff who stated R1 used the call button for assistance very frequently and they answered it right away.

LPA interviewed responsible party of other residents and according to them, facility staff is responsive to answer call button but it may take a little longer if they were busy with other residents.

After the investigation, this allegation is deemed to be unsubstantiated.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 14-AS-20220701103915

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: 04/24/2023

NARRATIVE

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Regarding to the allegation of - authorized representative is not provided resident's records in a timely manner, the reporting party stated that the responsible party requested for R1 and R2's COVID-19 vaccination record and after multiple attempts to request for it, the responsible party still has not received it.

LPA interviewed the former administrator, he/she did not remember of getting any medical record requests from the responsible party, however, the former administrator stated that the responsible party may have mentioned it to a staff such as the receptionist or a caregiver in passing but it was never formally requested from a facility director.

LPA interviewed responsible party of the other residents and all of them reported that they did not have any concerns regarding obtaining information from the facility.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to the allegation of - staff speak to residents in an inappropriate manner, the reporting party stated that R2 reported to his/her responsible party that staff told R1 that if R1 did not speak English, they would not assist R1 to the bathroom.

LPA interviewed 4 facility staff members and all of them denied the allegation and they reported that R1 did not speak English but they tried their best to communicate with R1 by using body language, hand gestures, etc.

LPA interviewed the responsible party of the other residents and all of them reported that they visited their loved ones several times a week and they have never witnessed facility staff speaking inappropriately to residents.

After the investigation, this allegation is deemed to be 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 reviewed and discussed with the business office director. A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 6

Control Number 14-AS-20220701103915

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: 04/24/2023

NARRATIVE

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Regarding to the allegation of- staff are mismanaging resident's medications, the reporting party stated that facility staff did not administered the medication that was prescribed by R1's physician.

As part of the investigation, LPA interviewed facility Medication Technicians (med tech) and a witness who had knowledge of this allegation.

According to the med techs, during R1's stay, they followed the physician's order, however, the responsible party took R1 to medical appointments and did not communicate the new orders upon return. In addition, when the facility learned about an new medication was prescribed, it took longer for the pharmacy to fill it as the ordering physician was from another city and the pharmacy needed to get an authorization before dispensing the medication.

According to the witness, facility staff tried to reconcile R1's medication several times but the responsible party was never satisfied and one of the contributing factor was the responsible party took R1 to medical appointments and did not communicate to the facility staff of any new physician's order(s).

Medication records received and reviewed.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding to the allegation of- staff are not properly trained, the reporting party stated that staff are not properly trained on feeding resident in memory care and transfers.

As part of the investigation, LPA interviewed the former administrator who denied the allegation and stated that facility staff were trained on providing care to residents with Dementia and other topics such as steps to take when resident has a change of condition related to behaviors, response time, alert charting/ incident reporting, Dementia Care, Assisting Medications, Alzheimer's Disease and Related Disorder, etc.

Based on the documents provided, LPA observed the completion of staff training.

In addition, LPA interviewed the responsible party of the other residents and all of them reported that they did not have any concerns with staff providing care to their loved ones.

After the investigation, this allegation is deemed to be unsubstantiated.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 14-AS-20220701103915

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: 04/24/2023

NARRATIVE

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Regarding to allegation of- staff do not safe guard resident's personal items, the reporting party stated that R2's personal belongs were missing from R2's room. For example, money was taken from R2's wallet, batteries, clothes and sunglasses were missing from the room.

LPA interviewed facility staff who reported that the responsible party reported some items missing from R2's room such as sunglasses, clothes, etc. but those items were found. In addition, some of the missing items were found in R2's room in the presence of the responsible party.

LPA interviewed the responsible party for the other residents and some of them reported that some items were misplaced and/or taken by another residents ( Memory Care Unit) but when it happened, they reported it and staff found the items.

After the investigation, this allegation is deemed to be unsubstantiated.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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