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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600429
Report Date: 08/10/2022
Date Signed: 08/10/2022 03:24:17 PM


Document Has Been Signed on 08/10/2022 03:24 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:COVENTRY PLACEFACILITY NUMBER:
385600429
ADMINISTRATOR:LIBHART, JILL C.FACILITY TYPE:
740
ADDRESS:1550 SUTTER STREETTELEPHONE:
(415) 921-1552
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:210CENSUS: 150DATE:
08/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Acting Administrator, Jeff SumabatTIME COMPLETED:
03:40 PM
NARRATIVE
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On 8/10/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220520135606. LPA met with the administrator and explained the purpose of the visit.

During the course of the investigation of an allegation concerning staff did not notify resident's responsible party of an incident in a timely fashion, according to the former administrator, resident #1's (R1) responsible party was recently changed and it was updated in R1's electronic medical record under resident's face sheet profile, however, the updated face sheet was not printed for R1's paper chart resulted staff contacting the former responsible party who was listed in R1's old face sheet.

Based on the complaint investigation, the facility did not ensure R1's current record is maintained which resulted R1's responsible party was not informed of R1's change of condition.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
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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Document Has Been Signed on 08/10/2022 03:24 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: COVENTRY PLACE
FACILITY NUMBER: 385600429

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/22/2022
Section Cited

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87506 Resident Records..(a) The licensee shall ensure..current record is maintained for each resident.b)Each resident’s record shall contain..(8)Names, address, and telephone numbers of the resident’s representative
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This requirement is not met as evidence by facility failed to update R1's responsible party (RP) information in R1's paper chart resulted staff contacting R1's old RP which poses a potential health and safety risk for persons in care.
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statement of acknowledging this process is done. The administrator and/or designee will provide in-services to staff on the importance of updating and maintaining resident's record current and will submit a copy of the in-service record to CCL by 8/22/2022.

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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022
LIC809 (FAS) - (06/04)
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