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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600429
Report Date: 04/14/2021
Date Signed: 04/16/2021 04:31:27 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
01/16/2020 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200116164013
FACILITY NAME:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:MARK NITSCHEFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 127DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mark NitscheTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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- Facility staff did not provide medical care to resident

- Facility staff did not notify resident's authorized representative of an unusual incident in a timely manner
INVESTIGATION FINDINGS:
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Complaint visit conducted virtually via FaceTime.

LPA Jeung interviewed staff and reviewed facility records, including Unusual Incident Report dated 12/27/19, which was submitted to CCLD on 1/8/20. Based on review of facility logs dated 12/27/19 and 12/29/19, staff observed that client #1 had a contusion on 12/29/19, not 12/27/19. Corrected Incident Report was submitted to CCLD with the correct incident date. Staff reported this to client's daughter on 12/29/19, and client was sent out for emergency medical treatment on the same day.

These allegations are unfounded, based upon investigation by this agency, meaning that they are determined to be false, could not have happened, and/or are without a reasonable basis.

This report is emailed to administrator, to be reviewed, printed, and signed. Signed copies will be returned to LPA via email or fax at 650/266-8841 within 24 hours.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
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
01/16/2020 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200116164013

FACILITY NAME:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:MARK NITSCHEFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 127DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mark NitscheTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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- Facility is in disrepair, resident's bed was broken
- Resident's records were not current
- Facility staff are not properly trained
- Facility staff did not keep the facility clean
INVESTIGATION FINDINGS:
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LPA Jeung's investigation included interviews with facility staff and review of staff training records for 2019.
Client #1 began hospice services from September 2019 until November 2019, and received a hospital bed from the hospice agency. After discharge from hospice, client continued to use the hospital bed. LPA obtained information that was inconsistent regarding the condition of the bed.

Complainant alleges that POLST was provided to facility upon admission and that facility staff did not have the POLST available when client was transferred to the hospital on 12/29/19. Facility staff deny that POLST was provided to them upon admission.

Based on review of staff training records provided to LPA, 4 out of 6 memory care staff received at least 20 hours of annual training required by CA Code of Regulations, including at least 8 hours of dementia training. Two memory care staff received less than 20 hours of continuing training and less than 8 hours of dementia training. However, staff training documentation submitted to CCLD may not be relied upon as complete. -Continued-

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20200116164013
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: 04/14/2021
NARRATIVE
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Continued from LIC9099A--Unsubstantiated:

Complaint alleges that food crumbs were observed in Sunflower Way room on more than one occasion. Facility employs housekeepers who are assigned to thoroughly clean rooms in the Enliven neighborhood once a week. Caregivers who are in clients' rooms multiple times daily do general tidying up, including making the beds and emptying the trash; food crumbs may not have been observed.

Although these allegations may have occurred or are valid, there is not a preponderance of evidence to prove nor disprove that the allegations did or did not occur. Based on this investigation, these allegations are determined to be unsubstantiated.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/16/2020 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200116164013

FACILITY NAME:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:MARK NITSCHEFACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 127DATE:
04/14/2021
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mark NitscheTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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- Resident received unexplained injury while in care
- Facility staff did not assist resident with hygiene needs
INVESTIGATION FINDINGS:
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Based on investigation by LPA Jeung--which included interviews and records reviews--former client was observed with a lump and hematoma on upper chest on 12/29/19; responsible party was notified and accompanied client to seek medical intervention. As documented in facility Service Plan upon admission in 9/2019, client required total assistance in personal hygiene and extensive assistance with feeding, due to 1/2019 stroke. Client was observed on more than one occasion with food in her mouth, which caregivers should have noticed. Service Plan was revised in 1/2020 with specific language added to make sure there is no food left in mouth after eating.

These allegations are determined to be SUBSTANTIATED, as the preponderance of evidence standard has been met.

Deficiencies of the California Code of Regulations, Title 22, are cited on a following page.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20200116164013
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/28/2021
Section Cited
CCR
87468.1(a)(2)
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PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES
Residents in all RCFEs shall have the personal right to be accorded safe, healthful and comfortable accommodations,furnishings and equipment. This requirement was not met, as former client #1 sustained a lump and hematoma on upper chest from unexplained blunt force trauma that was
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Plan of correction to be submitted to CCLD BY DUE DATE
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observed by staff on 12/29/19. Licensee failed to ensure client's right to safety, which posed a potential risk to health and safety of clients in care.
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Type B
04/28/2021
Section Cited
CCR
87464(f)(4)
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BASIC SERVICES
Basic services shall at a minimum, include personal assistance & care as needed by the resident & as indicated in the pre-admission appraisal, with those ADLs such as dressing, eating, bathing and assistance with taking medications. This requirement was not met, as staff failed to adequately assist client with eating.
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Plan of correction to be submitted to CCLD BY DUE DATE
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Licensee failed to ensure that client was provided with assistance to eat safely, as food remained in her mouth after meals. This posed a potential health and safety risk. Facility's Service Plan upon admission included total and extensive personal hygiene and feeding assistance by staff.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5