385600430-9-13-2021-14-AS-KHOS-C7BH6T-20210929055537

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600430
Report Date: 09/13/2021
Date Signed: 09/13/2021 11:40:33 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
04/28/2020 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200428130039

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: 102	DATE:	09/13/2021
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Katherine Tazawa		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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-- Resident sustained stage 2 pressure injury while in care.
-- Facility did not maintain adequate staffing to meet resident’s needs.
-- Facility did not coordinate care with hospice agency.
-- Facility did not assist resident with personal hygiene.
-- Facility did not wash resident’s clothes.

INVESTIGATION FINDINGS:

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On 9/13/2021, On behalf of Licensing Program Analyst (LPA) Michael Garcia, LPA Murial Han met with the Administrator, Katherine Tazawa to deliver the findings on the above allegations.

-- Resident sustained stage 2 pressure injury while in care.:

According to medical records, on April 17, 2020, the palliative nurse noted bed sore on Resident 1 (R1). On April 22, 2020, the hospice nurse noted R1 sustained stage 2 pressure injury on the coccyx while at the facility.

According to facility records, R1 did not require continuous bed care per R1’s Physician’s Report dated January 26, 2020 and required stand-by assistance only when turning in bed or in chair per R1’s Resident Appraisal dated January 29, 2020. No special instruction given for facility staff to follow regarding bed sore in R1’s Resident Appraisal or Physician’s Report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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-20200428130039

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: 09/13/2021

NARRATIVE

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According to staff interviews, two (2) out of seven (7) facility staff stated that there were times R1 refused care. Staff 3 (S3) stated that R1 was able to reposition independently while in bed and that R1 was encouraged to get up to avoid developing bed sores. Staff 4 (S4) stated that pillows were placed to reposition R1 but R1 kept removing it.

-- Facility did not maintain adequate staffing to meet resident’s needs.

According to facility records, a private caregiver was assigned to R1 for three days during the first week of April 2020.

According to staff interviews, Staff 2 (S2) and S3 stated that the private caregiver was to provide companionship to R1 and not due to the facility having insufficient staff.

According to facility records, R1 was seen by facility staff regularly for meals, medications, temperature checks, and showers.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20200428130039

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: 09/13/2021

NARRATIVE

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-- Facility did not coordinate care with hospice agency.

According to staff interviews, administrator stated that R1 developed a fever on April 18, 2020, and the facility contacted 9-1-1. The person responsible for R1 refused to send R1 to the hospital and wanted to place R1 under hospice care according to administrator. Administrator stated that there was no discussion of placing R1 under hospice care prior to this incident. S2 stated that there were back and forth discussion between R1’s family, the facility, and palliative team about placing R1 under hospice care but it was not finalized due to R1’s family was not ready to place R1 under hospice care.

According to R1’s Physician’s Report, R1 was not under hospice care as of January 26, 2020.

According to hospice records, R1’s goals of care were discussed with family and palliative team on April 17, 2020. It was noted on the hospice report that the family wishes to avoid hospitalization at this time and a hospice referral was made. However, the note was dated April 20, 2020, and the fax cover sheet addressed to the facility was dated April 22, 2020. R1 was placed under hospice care from April 18, 2020 – April 22, 2020 per hospice records.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 14-AS-20200428130039

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: 09/13/2021

NARRATIVE

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- Facility did not assist resident with personal hygiene.

According to R1’s physician’s report, R1 was unable to bathe independently.

According to facility staff’s assessment, R1 needed 1-person assistance with dressing, hair care and personal hygiene, and stand-by assistance twice a week for bathing.

According to R1’s April 2020 shower schedule, there were times that showers were needed to be rescheduled due to R1’s refusal but were still given twice per week, except when R1 transferred out of community due to R1 refused to be showered as noted by facility staff.

According to staff interviews, R1 received grooming and shaving services from facility staff daily and was showered almost daily due to incontinence care according to S2. R1 was able to comb and shaved independently according to S3. S4 stated that grooming service was provided R1 daily.

-- Facility did not wash resident’s clothes.:

According to R1’s laundry schedule, facility staff provided laundry service to R1 every Monday from February 03, 2020 to April 13, 2020. There was no staff documentation for the April 20, 2020 laundry schedule.

R1 transferred to another facility on April 22, 2020 according to administrator’s notes.

According to staff interviews, one staff stated that R1’s laundry was not washed after R1 tested positive for COVID-19 until R1 transferred to another facility but R1 had enough clean clothes to wear each day. Two staffs stated that laundry service was provided to R1 weekly per laundry schedule. Three staffs stated that S2 personally washed R1’s laundry after R1 tested positive for COVID-19. S1 and S2 stated that extra laundry service was provided to R1 as part of incontinence care service but was not documented according to S1. R1 always had clean clothes to wear according to S1 and S2 and S3.

The allegations were deemed UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

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