385600429-3-22-2021-14-AS-KHOS-BZLJZA-20210330072914

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 03/22/2021
Date Signed: 03/22/2021 11:32:00 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/11/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200311151130

FACILITY NAME:	COVENTRY PLACE		FACILITY NUMBER:	385600429
ADMINISTRATOR:	MARK NITSCHE		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 160	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Mark Nitsche, Administrator		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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- Staff refusing to allow resident to have visitor(s)
- Staff refusing to allow resident to receive phone calls

INVESTIGATION FINDINGS:

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Licensing Program Analyst, LPA Raygoza made an unannounced subsequent virtual visit regarding the above allegations.

- Staff refusing to allow resident to have visitor(s). During the course of the investigation the following came forth, the visitor limited allowance was adhered to by facility due to COVID pandemic times. Facility following mask and visitation policy in accordance with CDC guidelines. Also, Visitors were limited for R1 due to an occurrence of two visitors having a physical fight in R1's presence. In order to avoid the two visitors having another physical altercation in R1's presence, the visitor was not allowed to facility. On 12/7 SFPD was called due to R1 had two visitors with an outcome of an altercation and physical fight. In order to avoid another scene erupt Facility limited visitors. R1's POA requested limited visitors. The two visitors altercations were a civil matter. Therefore, the allegation was unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20200311151130

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: COVENTRY PLACE	FACILITY NUMBER: 385600429
	VISIT DATE: 03/22/2021

NARRATIVE

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- Staff refusing to allow resident to receive phone calls. R1 is allowed phone calls and has free telephone access in the receiving/living room area in Memory Care quarters. According to two staff and ombudsman interviews, R1 has access to a phone. When needed R1 can request staff to assist R1 with any phone call wished to be placed or received. Therefore, the allegation was deemed unsubstantiated.

Although the allegations 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 allegations are unsubstantiated at this time.

This report was discussed and reviewed with Administrator, Mark Nitsche.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2021

LIC9099 (FAS) - (06/04)

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