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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 08/10/2022
Date Signed: 08/10/2022 02:40:46 PM


Document Has Been Signed on 08/10/2022 02:40 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:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:LIBHART, JILL C.FACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 150DATE:
08/10/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Acting Administrator, Jeff SumabatTIME COMPLETED:
03:00 PM
NARRATIVE
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On 8/10/2022, Licensing Program Analyst (LPA), Murial Han conducted an unannounced Health and Welfare check to observe if facility is following COVID-19 management procedures. LPA met with the acting administrator and explained the purpose of today's visit.

At 9:40 AM, LPA was provided a tour of the memory care unit by the acting administrator, regional nurse and memory care specialist. During the tour, LPA observed 2 out of 8 residents who tested positive for COVID-19 were participating in activities with the non-affected residents without face covering. Staff members reported that they were not aware that these residents tested positive. According to the acting administrator and the memory care specialist, the facility conducts a daily morning huddle with facility staff to discuss COVID-19 status in the unit. However, there was no documentation of the huddle meetings. These findings will be cited on LIC809 under Personal Rights of All Residents In Facilities as the facility did not provide a safe and comfortable environment for residents in care and Administrator Qualification and Duties as the facility did not communicate to staff of COVID-19 status.

In addition, during the facility tour, LPA observed residents who tested positive for COVID-19 were not reported to CCL and other positive cases were not reported to CCL within 24 hours as per Title 22 Division 6 Chapter 8 Reporting Requirement.

Based on observation, record review and interviews, 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.

This report is discussed with the administrator. A copy of this report and the Appeal Rights are provided.

SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 08/10/2022 02:40 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: COVENTRY PLACE
FACILITY NUMBER: 385600429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
08/12/2022
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 and comfortable..
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The administrator and/or designee will develop a plan to minimize the spread of COVID-19 such as cohorting residents based on COVID-19 status(see Provider Information Notices (PIN) 22-15- ASC Resident Cohort), and provide in-room activities.
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This requirement is not met as evidenced by 2 residents who tested positive for COVID-19 were observed participating in activities with non affected residents in the activity room which poses an immediate health and safety risks to persons in care.
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The administrator and/or designee will submit a copy of the plan to CCL. The administrator and/or designee will provide in-service on the plan and submit a copy of the in-service sign-in sheet to CCL by 8/12/2022.
Request Denied
Type A
08/12/2022
Section Cited
CCR87405(b)

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87405 Administrator - Qualifications and Duties..(b) The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee.
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The administrator and/or designee will develop a plan to ensure staff member receive proper communication of the resident's health condition before and during their shifts. The administrator and/or
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This requirement is not met as evidenced by the administrator failed to ensure to communicate to facility staff of resident's change of health condition which poses an immediate health and safety risks to persons in care.
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designee will provide in-service of such plan and provide a copy of the in-service record to CCL by 8/12/2022.
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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 08/10/2022 02:40 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: COVENTRY PLACE
FACILITY NUMBER: 385600429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited
CCR
87211(a)(2)

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87211 Reporting Requirements..(2) Occurrences, such as epidemic outbreaks..shall be reported within 24 hours either by telephone or facsimile to the licensing agency..
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The administrator and/or designee will review this regulation and provide an in-service to those staff who are assigned for reporting.
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This requirement is not met as evidenced by facility failed and delayed in reporting positive COVID-19 cases to CCL which poses a potential risks to persons in care.
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The administrator and/or will provide a copy of the in-service sign-in sheet to CCL by 8/22/2022.

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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3