385600430-9-13-2021-14-AS-KHOS-C7BH6S-20210929055536

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600430
Report Date: 09/13/2021
Date Signed: 09/13/2021 11:35:26 AM

Substantiated

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:	Administrator, Katherine Tazawa		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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-- Facility did not ensure changes in resident’s condition were reported to physician.

-- Facility has rodents.

-- Facility is not clean.

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.

-- Facility did not ensure changes in resident’s condition were reported to physician.

According to medical records, on April 17, 2020, the palliative nurse noted bed sore on Resident 1 (R1) and that R1 often complain of pain and doesn’t want to be turned. On April 22, 2020, the hospice nurse noted R1 developed stage 2 pressure injury on the coccyx.

According to administrator, communications with residents’ Primary Care Physician (PCP) are either verbal or in writing, via fax, and it is documented in the facility’s electronic file system.

According to staff interviews, two (2) out of six (6) staff stated that skin redness was observed on R1. Staff 4 (S4) confirmed that redness was observed on R1’s coccyx on or after April 16, 2020. However, it may have not been recorded on the facility’s communication log according to S4.

According to facility records, there was no documentation recorded by facility staff that R1 was in pain or doesn’t want to be turned or had skin redness or bed sore or pressure injury. There was no staff documentation either that the PCP was contacted for the reasons stated above.

Substantiated

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)

Page: 1 of 5

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 has rodents.

According to staff interviews, administrator stated that mouse traps were placed in R1’s apartment and at least two mice were caught since R1’s admission at the facility.

According to the facility's maintenance director, the facility maintains a log of pest sightings and has ongoing monthly pest control service to prevent rodents in the facility. A pest control report is given for each service according to the maintenance director.

According to the facility’s 2020 Sighting Log, multiple residents reported seeing rodents at the facility. According to the Service Inspection Reports (SIR) from the exterminator company, rodent activities were noted from 3 out of 23 rodent bait stations on February 25, 2020 and 8 out of 23 rodent bait stations on June 30, 2020. It was noted on the SIR that the back door leading to the courtyard was propped open which creates a possible pest entry point to the facility.

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: 2 of 5

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 is not clean.

According to facility records, housekeeping is on a weekly basis per R1’s admission agreement. Facility maintains a log of housekeeping service provided. Facility staff documented that housekeeping service was provided to R1 every Monday from February 3, 2020 to April 6, 2020. However, there was no documentation recorded for April 13, 2020, April 20, 2020 and April 27, 2020. The next recorded housekeeping service was on May 4, 2020, as documented by facility staff.

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

According to housekeeping director’s email dated May 4, 2020, no housekeeping service was provided to R1 after April 13, 2020 after finding out that R1 tested positive for COVID-19.

According to staff interviews, Staff 4 (S4) stated that facility staffs were afraid to go inside R1’s apartment after learning that R1 tested positive for COVID-19. S4, S3 and S8 helped in cleaning R1’s apartment but they could not maintain it according to S4. Trash inside R1’s apartment was not picked up and there were times that food trays were not picked up as well according to S4. The next housekeeping service provided to R1 was when R1 left the facility according to S4.

The allegations were SUBSTANTIATED, meaning that the allegations were valid because the preponderance of the evidence standard has been met. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, Katherine Tazawa and Appeal Rights provided.

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: 5 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 09/27/2021 Section Cited CCR 87613(c)	1 2 3 4 5 6 7	General Requirements for Restricted Health Conditions. (c) The licensee shall document any significant occurrences that result in changes in the resident’s physical, mental and/or functional capabilities and immediately report these changes to the resident’s physician and authorized representative.	1 2 3 4 5 6 7	Administrator shall ensure to develop a plan of action describing how the facility will ensure that changes in the resident’s physical, mental and/or functional capabilities are immediately reported to the resident’s physician and authorized representative and submit a copy of it to the licensing office by the POC due date, 9/27/2021
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews and record reviews, the licensee failed to document R1's pressure injury and failed to report it immediately to R1's physician and authorized representative which posed an immediate health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/13/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 09/27/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation. (a) The facility shall be clean, safe, sanitary and in good repair at all times.	1 2 3 4 5 6 7	Facility has a COVID-19 mitigation plan. In addition, administrator shall ensure to provide a plan of action describing how the facility will ensure that the facility's mitigation plan regarding sanitizing and keeping the
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on staff interviews and records review, the licensee failed keep R1's apartment clean from after 04/13/2020 - 05/04/2020 which posed potential health and safety risks to resident in care.	8 9 10 11 12 13 14	facility clean, including resident's apartments with COVID19, are being followed. Plan of action is due to licensing by the POC due date, 9/27/2021.
Type B 09/27/2021 Section Cited CCR 87307(d)(2)	1 2 3 4 5 6 7	Personal Accommodations and Services. (d)... (2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.	1 2 3 4 5 6 7	Facility has a monthly pest control service to keep the facility rodent free. In addition, administrator shall ensure to provide a plan of action describing how to ensure possible pest entry point(s) are closed at all
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on staff interviews and records review, the licensee failed to keep the back door leading to the courtyard closed which creates possible pest entry point to the facility which poses potential health and safety risk to residents in care.	8 9 10 11 12 13 14	times. Plan of action is due to licensing by the POC due date, 9/27/2021.

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 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC9099 (FAS) - (06/04)

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