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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600430
Report Date: 04/19/2022
Date Signed: 04/19/2022 11:34:19 AM


Document Has Been Signed on 04/19/2022 11:34 AM - 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: 106DATE:
04/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Administrator, Kevin HoganTIME COMPLETED:
11:40 AM
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On 4/19/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on a visit that LPA conducted on 3/30/2022 concerning the facility reported that on 3/28/22 that resident #1(R1) AWOL (Absent Without Official Leave) on 3/24/22. LPA met with the administrator and explained the purpose of the visit.

During the visit on 3/30/22, LPA interviewed facility director who stated that on 3/24/22 at 8:44pm, the director of sales informed the facility director that R1 was missing. The facility director went to check R1's apartment and R1 was not there. Therefore, the facility started searching for R1 and the facility was informed later on from R1's responsible party that R1 had left the facility and went home.

According to the facility director, R1 was newly admitted to the facility and the facility's protocol was to provided frequent checks of R1 twice per shift. However, the facility was not able to provide any documentation of the frequent checks and the facility director stated that no one knew when R1 was last seen at the facility and when R1 exited the facility.

Furthermore, the facility director stated that on 3/24/2022, R1's dinner was delivered to R1's apartment at 4-5 PM, however, the staff left the meal in the apartment and did not check if R1 was there or not and R1's dinner tray was not picked up by facility staff that night.

Based on interview, and record review during the course of the investigation, the facility did not ensure basic services were being met, due to lack of supervision, R1 AWOL..

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC 809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with administrator. Appeals Rights were given.

A copy of report was provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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 04/19/2022 11:34 AM - 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CYPRESS AT GOLDEN GATE
FACILITY NUMBER: 385600430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited

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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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This requirement is not met as evidenced by: the facility did not ensure basic services were being met, due to lack of supervision R1 AWOL, which poses an immediate health, safety and personal rights risk to residents.
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The administrator and/or designee will provide caregiver training on proper documentation when frequent checks of residents were rendered and will submit a copy of the lesson plan and the sign-in sheet to CCL by 4/21/22.

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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) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
LIC809 (FAS) - (06/04)
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