<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600430
Report Date: 03/30/2022
Date Signed: 03/30/2022 02:18:39 PM


Document Has Been Signed on 03/30/2022 02:18 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CYPRESS AT GOLDEN GATEFACILITY NUMBER:
385600430
ADMINISTRATOR:TAZAWA, KATHERINEFACILITY TYPE:
740
ADDRESS:1601 19TH AVENUETELEPHONE:
(415) 664-6264
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:138CENSUS: 109DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator, Kevin HoganTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 3/30/2022 Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit regarding to a self reported incident that was reported to CCLD on 3/28/2022 regarding resident #1 (R1) AWOL (Absent Without Official Leave). LPA Han met with the administrator and explained the purpose of the visit.

During today's visit, LPA gathered the following documents and interviewed the director of assisted living who stated that the facility was informed later on that day by the responsible party that R1 went home from the facility.

- Resident appraisal
- Level of Care Assessment
- Service Plan
- LIC 624 (Incident Report)
- LIC 602 (Physician's Report)

This case management visit requires further follow-up.

This report is reviewed and discussed with the administrator and the director of assisted living.

A copy is provided.



SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1