385600429-3-22-2021-14-AS-KHOS-BZLKCB-20210330074653

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 03/22/2021
Date Signed: 03/22/2021 12:49:20 PM

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
06/22/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200622121143

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:	11:30 AM
MET WITH:	Mark Nitsche, Administrator		TIME COMPLETED:	11:40 AM

ALLEGATION(S):

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- Facility does not have adequate staff to meet resident's hygiene needs
- Staff are not properly trained
- Facility's first aid kit is not fully supplied
- Resident's do not have access to drinking water
- Resident's do not have access to a telephone

INVESTIGATION FINDINGS:

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Licensing Program Analyst, LPA Raygoza made a virtual zoom complaint tele-visit regarding the above allegations. LPA Raygoza met with Mark Nitsche, Administrator and stated purpose of visit.

- Facility does not have adequate staff to meet resident's hygiene needs. Per staff roster of Memory Care staff is adequate staff on board to meet residents' needs. Based on staff interviews, there is sufficient staff on board to meet the needs of residents during all shifts. Therefore, the allegation is deemed unsubstantiated.
- Staff are not properly trained. Per Med Tech training log of 5/7/20, Med Tech had sufficient hours of proper medication training. Staff Interviews reveal that Med Techs are trained and versed in the proper procedures. Therefore, the allegation is deemed unsubstantiated.

Cont'd 9099C

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-20200622121143

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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Cont'd from 9099

- Facility's first aid kit is not fully supplied. On 6/26/20, LPA observed during virtual visit and via pictures submitted that the first aid kit is fully supplied and is properly equipped. Therefore, the allegation is deemed unsubstantiated.
- Resident's do not have access to drinking water. On 6/26/20, LPA observed during virtual visit and via pictures submitted that there is access to drinking water and juice. LPA also viewed water dispenser with water and a dispenser next to it with coffee. LPA viewed In memory care quarters a refrigerator with a water jug and juice jug available for residents to access for drinking. Therefore, the allegation is deemed unsubstantiated.
- Resident's do not have access to a telephone. On 6/26/20 during virtual visit, LPA requested staff to check the phone in the Memory Care area. Staff checked the phones and the phones had a buzzing noise readily available for placing a call. The phones did not appear to be out of commission and in fully working order. Staff interviewed stated that if resident needs to place a call staff is readily available to assist. Therefore, the allegation is 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: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

LIC9099 (FAS) - (06/04)

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