385600429-7-5-2023-14-AS-KHOS-CTLJDN-20230710065750

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 07/05/2023
Date Signed: 07/05/2023 01:01:28 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
04/25/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230425173240

FACILITY NAME:	IVY PARK AT CATHEDRAL HILL		FACILITY NUMBER:	385600429
ADMINISTRATOR:	JEFF SUMABAT		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 125	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Administrator, Ella Frick		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility is not meeting resident's dietary needs.
Facility did not respond to resident's emergency cord.

INVESTIGATION FINDINGS:

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On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230425173240. LPA Han met with the administrator and explained the purpose of the visit.

Regarding to allegation of facility is not meeting resident's dietary needs, there is no additional information forthcoming from the reporting party. However, resident-in-question (R1) stated that R1 likes the taste of the meals but R1 has chewing difficulties so R1 has requested for soft foods. However it was not honored despite several meetings with facility staff including directors.

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

Substantiated

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: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 14-AS-20230425173240

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 CATHEDRAL HILL	FACILITY NUMBER: 385600429
	VISIT DATE: 07/05/2023

NARRATIVE

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Based on documentation provided by the facility, R1 has a physician's order for mechanical soft diet, however, R1 was served raw bell peppers, and raw onions and R1 has provided written communication to facility directors reporting this incident.

According to facility Chef, he/she and the memory care director met with R1 on 5/18/2023 to reviewed R1's food preferences and improvements have been made.

According to facility staff, R1 has received food items that R1 was not able to chew and alternates were given upon R1's request.

After the investigation, this allegation is deemed to be substantiated as R1 was served a diet that was not prescribed by the physician.

Regarding to allegation of facility did not respond to resident's emergency cord, the reporting party stated on 4/20/2023 early morning, R1's roommate resident #2 (R2) fell and R1 pressed multiple call cords in the room, however, it was not responded by staff resulted R1 who has unsteady gait assisted R2 back into the bed.

As part of the investigation, LPA interviewed R1, interviewed administrator, and reviewed facility records.

R1 stated that on 4/20/2023 around 5- 6am, R1's roommate fell and R1 pressed the call cords in the room but no one came; R1 went outside of the room pleading for assistance but no one was around so R1 had to assist R2 back to bed.

According to the Device Activity Report(this report reveals the call cord response time) that was provided by the facility, it revealed that on 4/20/2023, call cord was activated in R1 and R2's room at 5:53AM and the reset time was 205 minutes and 46 seconds and according to the administrator, the reset time was the time when staff answered the call cord and reset it.

Furthermore, LPA observed on the same report that another apartment on 5/3/2023, call cord was activated at 2:32 AM and the reset time was 210 minutes and 42 seconds.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 14-AS-20230425173240

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 CATHEDRAL HILL	FACILITY NUMBER: 385600429
	VISIT DATE: 07/05/2023

NARRATIVE

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After the investigation this allegation is deemed to be substantiated. In addition, a separate deficiency will be issued on a LIC 809 (Case Management Report) as facility staff failed to assist R2 back to bed after the fall.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 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
04/25/2023 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20230425173240

FACILITY NAME:	IVY PARK AT CATHEDRAL HILL		FACILITY NUMBER:	385600429
ADMINISTRATOR:	JEFF SUMABAT		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 125	DATE:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Ella Frick		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Facility is not providing laundry services for resident.

INVESTIGATION FINDINGS:

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On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230425173240. LPA Han met with the administrator and explained the purpose of the visit.

Regarding to allegation of - facility is not providing laundry services for resident, there is no additional information forthcoming from the reporting party. However, according to resident- in -question (R1), R1 was not receiving laundry services on a regular basis so R1 pay out of pocket to have someone come in once a week to assist with laundry services.

As part of the investigation, LPA reviewed documents that was provided by the facility, interviewed facility director, former administrator and R1.

According to R1's individual service plan, R1's laundry services is provided by someone from an agency once a week.

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: 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.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 14-AS-20230425173240

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 CATHEDRAL HILL	FACILITY NUMBER: 385600429
	VISIT DATE: 07/05/2023

NARRATIVE

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According to R1, it was difficult to get laundry services in the beginning of R1's stay but now R1 prefers to have the weekly laundry service that is provided by someone from an agency.

According to the memory care director and the former administrator, R1's laundry services is provided by someone who comes in once a week but facility will do it if needed as indicated on R1's individual service plan.

Based on interviews, observations and record reviews during the course of the investigation, this allegation is deemed to be unsubstantiated.

This report is reviewed and discussed with the administrator.

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: 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

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 14-AS-20230425173240

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 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 CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1Personal 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,..	1 2 3 4 5 6 7	The administrator/licensee will submit a plan to ensure call cords are answered in a timely fashion; the plan shall include what method/system the facility will be utilizing to monitor call cord system response time and what actions
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: it took facility staff 205 minutes and 46 seconds to reset R1's call cord which posed an immediate health risk to residents in care.	8 9 10 11 12 13 14	will be taken when it is observed to be out of compliance; the plan shall also include staff training. A copy of this plan shall be submitted to CCL by the plan of correction due date of 7/6/2023.
Type B 07/14/2023 Section Cited CCR 87555(d)(7)	1 2 3 4 5 6 7	87555 General Food Service Requirements..(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met	1 2 3 4 5 6 7	The licensee/administrator will develop a plan to ensure resident's diet and diet preferences are honored as prescribed and obtained. The plan shall include what method/system will be utilizing to ensure compliance and
	8 9 10 11 12 13 14	as evidenced by: R1 has a physician's order for mechanical soft diet, however, facility served R1 raw vegetables and other foods that R1 was not to chew which posed a potential health risk to resident in care.	8 9 10 11 12 13 14	the plan shall include staff education including but not limiting to dietary staff members. A copy of this plan will be submitted to CCL by the plan of correction due date of 7/14/2023.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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