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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 07/05/2023
Date Signed: 07/05/2023 07:32:38 PM


Document Has Been Signed on 07/05/2023 07:32 PM - 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: 125DATE:
07/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Ella FrickTIME COMPLETED:
01:10 PM
NARRATIVE
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On July 5, 2023 Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20230425173240. LPA met with administrator and explained the purpose of the visit.

During the course of the investigation, Resident 1 (R1) stated that early morning of 4/20/2023 around 5-6AM, R1's roommate resident #2 (R2) fell. R1 pressed the call cords in the room and after a long period of waiting, R1 went outside of the room pleading for assistance, however, no one was available. Therefore, R1 went back to the room and assisted R2 off of the floor, back into bed.

According to the documentation provided by the facility, on 4/20/2023, it did not indicate that facility staff provided assistance to R2 after the fall.

Based on the complaint investigation, on the day of the fall, it took facility staff 205 minutes and 46 seconds to respond to R1's call cord and no one was available to assist R2 back to bed after fall which resulted R1 assisting R2 off of the floor and back to bed.

Deficient is cited under California Health and Safety Code on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and reviewed with administrator.

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: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
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 07/05/2023 07:32 PM - 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: 07/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/06/2023
Section Cited
HSC
1569.312(a)

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ยง1569.312Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services:..(a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by:
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The licensee/administrator will develop a plan to ensure resident's basic services are being met including but not limiting to provide assistance to residents in a timely fashion without which the resident's
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R1's roommate R2 fell and there was no staff around to provide assistance which resulted R1 assisted R2 off of the floor and back to the bed which posed an immediate health risk for residents in care.
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safety would be endangered. The plan shall include staff training. The plan shall be submitted to CCL by the plan of correction due date of 7/6/2023.

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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: 07/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/05/2023
LIC809 (FAS) - (06/04)
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