385600430-12-4-2020-14-AS-KHOS-BW5KKG-20201209065820

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600430
Report Date: 12/03/2020
Date Signed: 12/04/2020 11:49:07 AM

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
10/01/2020 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20201001114725

FACILITY NAME:	CYPRESS AT GOLDEN GATE		FACILITY NUMBER:	385600430
ADMINISTRATOR:	TAZAWA, KATHERINE		FACILITY TYPE:	740
ADDRESS:	1601 19TH AVENUE		TELEPHONE:	(415) 664-6264
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	138	CENSUS: 95	DATE:	12/03/2020
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Katherine Tazawa		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Staff are medically restraining the resident.
The staff are not meeting the needs of the resident.

INVESTIGATION FINDINGS:

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On 12/3/20, Licensing Program Analysts (LPA) Mohamed Filouane and LPA Murial Han, conducted a follow-up complaint inspection with Executive Director Katherine Tazawa, over the phone. LPAs spoke over the phone with the executive director, with the Director of Assisted Living, Angeline Reyes, and with Enliven Director, Daisy Dizon. LPAs spoke with the executive Director, explained the purpose of the phone call, and then delivered the findings.

Concerning the first allegation of staff medically restraining the resident, the Department conducted interviews with the complainant as well as the facility executive director and enliven director. During an interview with the complainant, the complainant recanted that the facility is medically restraining the resident. The executive facility director and enliven director also denied this allegation. The executive facility director stated that prescription medication is not used in other ways on residents except for how the resident's doctor prescribed the medication to be used. Medication records of the resident were requested and inspected. After review, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

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 3

Control Number 14-AS-20201001114725

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: CYPRESS AT GOLDEN GATE	FACILITY NUMBER: 385600430
	VISIT DATE: 12/03/2020

NARRATIVE

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Concerning the second allegation of staff not meeting the needs of the resident, the Department investigated the resident's needs and services plan, the resident's behavioral plan, the resident's medication records, incident reports submitted to the Community Care Licensing Division (CCLD), facility staff training files, and interviewed facility staff members along with one family member. The investigation revealed the resident has a history of incidents reported to CCLD involving hitting, scratching, as well as throwing items at facility staff and other facility residents. The incident reports state the resident's aggressive behavior has an unknown trigger, and when the resident is triggered, staff have reported using their bodies to protect themselves or other facility residents. During an interview, a staff member stated the husband of the resident is aware of the resident's aggressive behavior.

The interviews conducted indicated that the resident's behavior is unpredictable. Staff members stated that the resident can be calm and then immediately become aggressive with whoever is nearby. Staff members have confirmed that they had, at one point, used their bodies to block the resident in question's attacks on other residents. When confirming the resident's reported behavior to CCLD from prior incident reports, staff stated the resident is sweet and calm, but there is something that triggers her aggressive behavior.

In interviews with the facility executive director and enliven director on 11/18/20, LPA Filouane requested an update on the resident. The facility executive director stated the resident has a one on one program with the enliven director and that the resident's husband continues to visit daily. According to the facility executive director and enliven director, the resident is still combative with facility staff and other residents. The facility executive director and enliven director both agreed that the resident in question's behavior has slightly improved. The facility executive director and enliven director also stated that the private duty attendants hired to care for the resident are able to lessen the resident's anger and keep the resident calm. Because the resident speaks another language, the facility executive director has located an agency that can provide a private duty attendant that speaks the same language as the resident. It has been reported through interviews that the resident is at ease when speaking their first language.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20201001114725

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: CYPRESS AT GOLDEN GATE	FACILITY NUMBER: 385600430
	VISIT DATE: 12/03/2020

NARRATIVE

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In the 11/18/20 update interview, LPA Filouane also questioned if the facility had been submitting recent incident reports to CCLD. The facility executive director stated there have been no incident reports filed concerning the resident. Both facility executive director and enliven director agreed and stated that the additional support from the hired private duty attendants is essential to the care of the resident.

Although the above 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.

Exit interview conducted with the facility executive director over the phone. The facility executive director will receive this LIC9099 report through email to sign. The facility executive director will then email the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC9099 (FAS) - (06/04)

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