385601097-4-20-2023-14-AS-KHOS-CRFK27-20230502073041

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 04/20/2023
Date Signed: 04/20/2023 01:05:07 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
02/03/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230203085150

FACILITY NAME:	SUTRO HEIGHTS CORPORATION		FACILITY NUMBER:	385601097
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	659 45TH STREET		TELEPHONE:	(415) 571-8531
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	14	CENSUS: 12	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Oscar Madrigal		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility staff not maintaining resident’s hygiene.
Facility staff serves cold meal(s) to resident.
Facility staff not keeping resident’s legs free from pests.

INVESTIGATION FINDINGS:

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On 4/20/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230203085150. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit.

Regarding to the allegation of facility staff not maintaining resident's hygiene, the reporting party stated that resident #1 (R1) was not showered in 20 days.

As part of the investigation, LPA interviewed R1, other residents, facility staff and reviewed records.

According to R1, R1 was not showered for a long time but R1 was provided with a bed bath 2-3 times per week.

According to resident #2 (R2), R2 was supposed to get a shower at least once a week but R2 has only gotten one in 8 weeks but R2 was provided with a bed bath almost daily.

According to resident #3 (R3), R3 did not remember when facility staff provided him/her a shower but R3 was provided with a bed bath a few times a week and R3 preferred having showers every week.

Based on the facility's shower schedule, R1, R2 and R3 were supposed to be showered every week.

Based on December 2022 and January 2023 vital signs and Activities of Daily Living (ADLs) logs for R1, R2 and R3, LPA observed under the shower slots, there were all blank and facility staff reported it was an indication that shower was not provided.

According to staff #1 (S1) and staff #2 (S2), facility provided R1, R2, and R3 bed baths but not showers.

After the investigation, this allegation is deemed to be substantiated.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

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 6

Control Number 14-AS-20230203085150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
	VISIT DATE: 04/20/2023

NARRATIVE

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Regarding to the allegation of facility staff serves cold meals to resident, the reporting party stated that R1 was served a lot of cold meals and facility was not following R1's diet needs.

As part of the investigation, LPA interviewed R1, other residents and facility staff.

According to R1, the facility is following the diet restriction and R1 liked the foods but sometimes it was served cold.

According to R2, R3, and resident #4 (R4), the food was good but it was served cold and they had to request facility staff to heat it up.

LPA interviewed S1 who stated that he/she was not aware that the meals were served cold but many residents asked it to be heated up.

After the investigation, this allegation is deemed to be substantiated.

Regarding to the allegation of facility staff not keeping resident's legs free from pests- the reporting party stated that there were ants crawling on R1's toes and knees.

As part of the investigation, LPA interviewed R1, staff and hospice nurse.

According to R1, there were ants crawling on R1's toes.

LPA interviewed S1 who acknowledged that there were ants observed to be crawling on R1's toes and it was reported to the administrator.

According to hospice nurse, there were ants on R1's bed and by R1's lower extremity.

After the investigation, this allegation is deemed to be substantiated.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. 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, a copy is provided and Appeal Rights provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 14-AS-20230203085150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/21/2023 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services..(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified ..	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure residents are provided with showers according to the schedule. The administrator will submit a copy of the plan and a copy of the shower schedule to CCL by 4/21/2023.
	8 9 10 11 12 13 14	This requirement is not met as the facility did not assist resident with showers for many weeks as scheduled which poses an immediately health risk to resident in care.	8 9 10 11 12 13 14
Type A 04/21/2023 Section Cited CCR 87468.19a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities..a) Residents in all residential care facilities for the elderly shall ...(2) To be accorded safe, healthful and comfortable accommodations,...	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure residents are being cared for in a comfortable, healthful and sanitized environment. The administrator will submit a copy of the plan to CCL by 4/21/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by S1 and home health staff acknowledged that they have observed pest crawling on R1's lower extremity and on the bed which poses an immediately health risk for resident in care.	8 9 10 11 12 13 14

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 14-AS-20230203085150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/27/2023 Section Cited CCR 87468.2(a)(5)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents...(5)To be served food of the quality and quantity necessary to meet their nutritional needs.	1 2 3 4 5 6 7	The administrator/Licensee will develop a plan to ensure residents are being served quality food and the plan needs to indicate who is going to ensure compliance. The administrator/licensee will submit
	8 9 10 11 12 13 14	This requirment is not met as evidenced by residents are experiencing being served cold meals which poses a potential health risk to residents in care.	8 9 10 11 12 13 14	a copy of the plan of correction to CCL by 4/27/2023.
	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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
02/03/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230203085150

FACILITY NAME:	SUTRO HEIGHTS CORPORATION		FACILITY NUMBER:	385601097
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	659 45TH STREET		TELEPHONE:	(415) 571-8531
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	14	CENSUS: 12	DATE:	04/20/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Oscar Madrigal		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff not meeting resident’s dietary needs.

INVESTIGATION FINDINGS:

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5
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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 14-AS-20230203085150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
	VISIT DATE: 04/20/2023

NARRATIVE

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LPA interviewed facility staff and both of them were aware R1 and R2's special dietary needs and they stated that they followed it every meal.

After the investigation, this allegation is deemed to be unsubstantiated.

Although the above investigations 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 allegation is UNSUBSTANTIATED.

This report is discussed and review with manager.

A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/20/2023

LIC9099 (FAS) - (06/04)

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