385600429-9-23-2023-14-AS-CVAO-CVY2R5-20230923173655

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 09/23/2023
Date Signed: 09/23/2023 05:37:04 PM

Document Has Been Signed on 09/23/2023 05:37 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	IVY PARK AT CATHEDRAL HILL		FACILITY NUMBER:	385600429
ADMINISTRATOR:	ELLA FRICK		FACILITY TYPE:	740
ADDRESS:	1550 SUTTER STREET		TELEPHONE:	(415) 921-1552
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	210	CENSUS: 128	DATE:	09/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Marketing Director, Michelle Herman		TIME COMPLETED:	06:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Christina Valerio and LPA Arielle Pascua arrived to the facility unannounced to conduct an annual required inspection. LPA met with front desk staff, and explained the purpose of the visit. LPAs were met by Marketing Director (MD), Michelle Herman, and informed us that Administrator Ella Frick appointed Michelle to carry out the visit. LPAs toured the physical plant with MD Herman to ensure compliance with Title 22 regulations. The facility is a 5 floor building with Assisted Living Rooms and a Memory Care Living Space. LPAs toured each floor and inspected random resident apartments. Rooms were observed to be clean, organized, free from debris, and free from odors. All emergency exits were clear from obstructions. Common areas and dinning rooms were observed to be clean. Water temperature in the bathrooms delivered hot water at 109.8 degrees Fahrenheit and 114.3 degrees. Kitchen areas were observed to be clean and free from any debris. The facility was observed to have a food supply to meet the requirements of non-perishable food items for 7 days and perishable items for 2 days. An emergency supply of food and water was observed in a locked storage area. Medications, cleaning supplies, and toxins were observed to locked away and inaccessible to residents in care. LPAs observed 2 elevators. The inspections for the annual inspection had an expiration date of 01/24/2019. According to MD Herman, the City has not done inspections due to COVID, however, the Maintenance Director will follow up to see if inspections have resumed. Residents in the Assisted Living areas were observed to be enjoying pastries and coffee in the cafe, watching a movie in the cinema room, eating snacks, engaging in family visits, reading newspapers, and walking around the building. Staff were observed assisting residents, cleaning common areas and apartments, assisting with medications, and completing administrative tasks. Continues on LIC 809-C...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: IVY PARK AT CATHEDRAL HILL	FACILITY NUMBER: 385600429
	VISIT DATE: 09/23/2023

NARRATIVE

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Continued from LIC 809

LPAs inspected 10 resident files. 8 out of 10 resident files reviewed did not have an updated LIC 602 or an LIC 602 located in the file. 4 out of 10 resident files reviewed did not have a resident appraisal on file.

LPAs inspected 5 staff files. Staff files were observed to be current and up to date.

LPAs spoke to Administrator Ella Frick via cell phone to discuss licensing fees that were observed to be past due. Administrator Ella stated that it may be an administrative error and will provided additional information to LPA on 09/25/23. Technical Assistance was provided.

LPA requested the following documentation be sent to their assigned LPA/Regional Office: LIC 500, LIC 308, Liability Insurance Information, and LIC 610D

Per California Code of Regulations (CCR) - Title 22, Division 6, Chapter 8, deficiencies are being cited today on the LIC 809 - D page. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided. An exit interview was held with MD Herman, and a copy of the report was provided in-person.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2023 05:37 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
SAN BRUNO RO, 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: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87203

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation of 2 elevators, the licensee did not ensure elevators were inspected annually in 2 out of 2 which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee will schedule a inspection for the elevators and send updated certification to LPA by POC due date.

Type B

Section Cited

CCR

87458(a)

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 8 out of 10 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee will send a statement of acknowledgement of regulation 87458 by POC due date and ensure all residents have a current LIC 602 located in their file.

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2023 05:37 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
SAN BRUNO RO, 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: 09/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

87463 Reappraisals (c)The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff, and a representative of the resident’s home health agency, if any, when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 4 out of 10 resident files, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee will review regulation 87463 and send a statement of understanding to LPA by POC due date. Licensee will ensure that all residents files have a current Appraisal/Needs and Services Plan.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

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