385600429-12-15-2023-14-AS-KHOS-CZ4RHD-20240102120210

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 12/15/2023
Date Signed: 12/15/2023 12:39:00 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
11/28/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231128101756

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: 126	DATE:	12/15/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Executive Director, Ella Frick		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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-Staff did not administer resident's medication as prescribed
-Staff do not answer resident's call button in a timely manner

INVESTIGATION FINDINGS:

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On December 15, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Executive Director, Ella Frick and explained the purpose of the visit.

Regarding the allegation, staff did not administer resident's medication as prescribed, according to the reporting party, Resident 1 (R1) should be receiving 200mgs of a prescribed medication daily. In addition, reporting party indicated that the prescribed medication comes in 100mg tablets so R1 should be receiving two tablets a day in the morning, the facility’s instructions were to provide one tablet a day.

During the visit, LPA interviewed staff, observed R1's medications, reviewed R1's physician's orders and MAR. Based on documentation reviewed, LPA observed a discrepancy between the physician's order, the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy. According to the physician's order and the MAR system, R1 was prescribed 200mgs tablet of Lamotrigine and instructions were to take 1 tablet by mouth daily per physician's order. However, based on observations, R1's Lamotrigine prescription bottle contained 100mg tablets and instructions were to take 2 tablets (200mg) by mouth daily. The facility observed the discrepancy, however failed to contact the physician and/or the pharmacy for clarification.

On 11/30/23, LPA conducted a complaint visit and observed R1's Lamotrigine prescription bottle. R1 started his/her prescription bottle of Lamotrigine (100mg/quantity 180 tablets) on 8/23/2023. During the visit on 11/30/2023, LPA observed 8 tablets in the bottle. Based on MAR review, R1 has never refused his/her Lamotrigine prescription. In addition, based on staff interviewed, R1 should have started a new prescription bottle on 11/22/2023. Furthermore, based on staff interviewed, it was observed that a staff member accidentally gave R1 one tablet of Lamotrigine, however caught the issue and provided R1 another tablet. (CONT. TO 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

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-20231128101756

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: 12/15/2023

NARRATIVE

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Regarding the allegation, staff do not answer resident's call button in a timely manner, according to the reporting party, within the last six months, there has been issues with staff not responding to call buttons. In addition, according to the reporting party, R1 pressed his/her call button for help and was left waiting for two hours.

During the investigation, LPA reviewed R1’s call records and observed on 11/20/2023, R1 pressed his/her call button at 7:44am, however a staff did not respond to R1’s call button request until 8:52am, 67 minutes after pressing the call button. In addition, on 9/26/23, R1 pressed his/her call button at 7:43am and a staff member did not respond to the call pendant till 8:38am, 55 minutes after pressing the call pendant. In addition to reviewing R1’s record, additional resident records were reviewed. During additional record review, LPA observed Resident 2 (R2) pressed his/her call button on 9/8/23 at 6:46am and staff responded 120 minutes later at 8:52am. Furthermore, R2 pressed his/her call button on 9/7/23 at 11:13am and staff did not respond till 12:33am, 80 minutes after R2 pressed his/her button for assistance.

Based on interviews, observations and record review during the investigation, the preponderance of evidence standard has been met. Therefore, the above 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.

§1569.312 Basic services(a)- A civil penalty of $1,000 is assessed on 12/15/2023 for a repeat violation within 12 months. This violation was cited on 7/5/2023.

Report was discussed with Executive Director, Ella Frick and a copy is provided with appeal rights. A copy of civil penalty is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231128101756

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: 12/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/22/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility...The plan shall encourage routine medical and provide for assistance in obtaining such care, by compliance with the following: (4)The licensee shall assist residents with self-administered medications as needed. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to provide in-service training with staff and med-techs to ensure that residents are receiving prescription medication as prescribed by the physician. In addition, training shall include facility protocols if there is a discrepancy with physician's orders and the presciption bottle given by the pharmacy
	8 9 10 11 12 13 14	Based on interviews conducted, a staff member observed another staff member accidentally give R1 one tablet instead of two tablets, however caught the issue and provided R1 with another tablet. Based on record review, there was a discrepancy between a discrepancy between the physician's order and the MAR system being used by the facility, and the prescription bottle that was given by the pharmacy as the MAR system and the physician’s order indicated to provide R1 with one 200mg tablet of Lamotrigine daily, however the prescription bottle from the pharmacy indicated to provide R1 with two 100mg of Lamotrigine tablets daily. Nevertheless, the facility failed to provide R1 with his/her Lamotrigine prescription as prescribed by R1’s physician and follow up with R1's physician and/or the pharmacy for clarification	8 9 10 11 12 13 14
Type A 12/16/2023 Section Cited HSC 1569.312(a)	1 2 3 4 5 6 7	§1569.312 Basic 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. Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator to conduct an in-service training with staff to turn off call buttons and call pendants after responding to residents calls. Training shall also include the importance of responding to residents in a timely manner
	8 9 10 11 12 13 14	Based on record reviewed, on 11/20/23, R1 pressed his/her call button and a staff member responded 67 minutes later. In addition, on 9/26/23, staff did not respond to R1’s call button in a timely manner as a staff responded to R1’s call 55 minutes after he/she pressed her button. Furthermore, additional record reviewed showed that it took staff 80 minutes on 9/7/23 and 120 minutes on 9/8/23 to respond to R2’s call button.	8 9 10 11 12 13 14	A civil penalty of $1,000 is assessed on 12/15/2023 for a repeat violation within 12 months. This violation was cited on 7/5/23

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: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2023

LIC9099 (FAS) - (06/04)

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