385601097-7-5-2023-14-AS-KHOS-CTLKAP-20230710074416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 07/05/2023
Date Signed: 07/05/2023 11:19:14 AM

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
04/14/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230414140716

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:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Manager, Oscar Madrigal		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility staff do not ensure that resident's room is ventilated.
Facility staff are not adequately trained.
Resident's wheelchair has gone missing.
Facility staff left the kitchen medicine cabinet unlocked.
Facility staff did not provide resident a list of their belongings upon request.
Facility staff leave resident restrained in their bed all day long.
Facility staff did not ensure that resident had appropriate size bed linens and blankets that are cleaned.
Facility staff mishandled resident's records.
Facility staff did not provide resident appropriative medical supplies.
Facility staff did not ensure that resident's hygiene needs are being met.
Facility staff does not speak language that resident understands.
Facility staff did not ensure that resident's food/drinks are served at the right temperature and offered resident

INVESTIGATION FINDINGS:

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On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230414140716. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit.

Regarding to allegation of - facility staff do not ensure that resident's room is ventilated, the reporting party stated that that resident #1 (R1) was transferred to a room without ventilation.

As part of the investigation, LPA interviewed R1, facility staff, and former assistant administrator.

During the initial complaint visit, LPA observed staff was providing a sponage bath to R1 in the room with the door closed and afterwards, LPA observed the room to be stuffy.

LPA interviewed R1 who stated that the room is unventilated when staff failed to open the door after they are done with providing care.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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According to facility staff, when they were providing care to R1, they closed the door to ensure R1's privacy and dignity are maintained but they also acknowledged that the room is unventilated when the door is closed.

The former assistant administrator acknowledged R1's room needed additional ventilation and the facility was considering getting a permit to install a window.

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

Regarding to allegation of- facility staff are not adequately trained, the reporting party stated that facility staff stated that they are not trained to use the hoyer lift.

As part of the investigation, LPA interviewed staff, requested for training records and interviewed resident #1 (R1).

LPA interviewed R1's caregivers regarding training on hoyer lift and both of them reported that they were not trained and they did not know how to use it.

According to the facility manager, there is no training records on hoyer lift.

LPA interviewed R1 who was in bed and required a hoyer lift for transfer. According to R1, R1 has been in bed for many months because facility staff did not know how to use the hoyer lift to get R1 out of bed.

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

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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Regarding to allegation of- resident's wheelchair has gone missing, the reporting party stated that R1's family member provided R1 a manual wheelchair in March 2022, however it has gone missing.

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

During the initial complaint visit on 4/20/2023, LPA interviewed R1 who stated that staff mistakenly handed over R1's wheelchair to a medical equipment company when the equipment company came to collect medical equipment for another resident. In addition, R1 stated that R1 has made contacts with the medical equipment company and they would return the wheelchair in a few days.

LPA interviewed staff #1 (S1) who stated that they thought R1's wheelchair belonged to another resident, therefore, they returned it to the company when they came.

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

Regarding to allegation of- facility staff left the kitchen medicine cabinet unlocked, during the initial complaint visit on 4/20/2023 at 11:50am, LPA observed the kitchen medicine was not locked and there was no staff present at the time to monitor.

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

Regarding to allegation of- facility staff did not provide resident a list of their belongings upon request, the reporting party reported R1's family member brought a wheelchair to the facility for R1 and R1 asked the former manager to put it on the belonging list. R1 requested staff to see the belonging list but it was never provided.

As part of the investigation, LPA interviewed R1, interviewed facility manager and reviewed record.

According to R1, R1 has requested to reviewed R1's belonging list but it has yet been provided. Therefore, R1 was unsure if the wheelchair was added to the belonging list or not.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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LPA reviewed R1's client/ resident personal property and valuables (LIC 612) and it was blank.

Facility newly hired manager acknowledged that R1's belonging list was mostly not provided to R1 for review as it was blank and inaccurate.

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

Regarding to allegation of- facility staff leave resident restrained in their bed all day long, the reporting party stated that facility staff was not trained on how to use the hoyer lift to transfer R1 from bed to wheelchair. Therefore, R1 was restrained to the bed which resulted R1 has not seen the sun for over 6 months and R1 just wanted to get some fresh air.

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

During the initial complaint visit on 4/20/2023, LPA observed R1 in bed, and R1 stated that R1 stayed in bed all day long as facility staff did not know how to use a hoyer lift to transfer R1 from bed to wheelchair. In addition, R1 stated that while R1 was receiving therapy from a home health agency, the therapist(s) trained facility staff on how to use a hoyer lift but most them are no longer working at the facility except for one but whenever he/she is scheduled to work, he/she claimed to be too busy and did not have time to get R1 out of bed.

According to S1 and staff #2 (S2), R1 stayed in bed all the time as R1 required to be transferred from bed to wheelchair with a hoyer lift and they were not trained on how to use it.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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According to R1's appraisal/needs and service plan, R1 required two person assist, R1 needs hoyer lift for transfer and under method of evaluating progress, it indicated that resident will show no signs and symptoms of isolation, and resident will participate with activities. However, facility failed to execute R1's appraisal/needs and service plan as staff was not trained on using a hoyer lift for transfers resulted R1 to be confined in bed.

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

Regarding to allegation of facility staff did not ensure that resident had appropriate size bed linens and blankets that are cleaned- the reporting party stated that R1 reported that the bed linens and top upper blankets have not been changed for over 3 weeks. The reporting party observed bed sheets were stained, and bed sheets were not the right size.

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

During the initial complaint visit on 4/20/2023, LPA observed stains on R1's bed linens, and the linen was tugged underneath the mattress.

According to R1, facility staff did not change the beddings for a couple of weeks and they stated that they did not have any cleaned beddings.

LPA interviewed S1 who reported that facility did not have any extra cleaned linens.

LPA observed there was no cleaned linens in the linen storage room.

According to the newly hired manager who acknowledged that facility did not have any linens/beddings in storage as the facility used all the supplies a few days ago when a resident had many episodes of diarrhea. After the incident, the facility discarded the soiled linens resulted no additional linens but facility is in process of purchasing new linens/beddings.

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

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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Regarding to allegation of facility staff mishandled resident's records- the reporting party stated that R1 suffers from constipation and facility staff was supposed to document on a log that was posted by R1's bed whenever R1 had a bowel movement. However, facility staff constantly failed to document it, therefore, it made it difficult for R1 to get the constipation medicine as there was no records showing when R1 had a bowel movement.

As part of the investigation, LPA interviewed R1, facility staff, manager and review the log.

Based on the March 2023 and April 2023 vital signs and ADL's logs, it revealed R1 did not have any bowel movements within those 2 months.

According to R1, R1 always reminded facility staff to document on the log whenever R1 had a bowel movement and they would verbally agree to do it but they would forget.

LPA interviewed facility staff who acknowledged that they failed to document properly when R1 had a bowel movement.

LPA interviewed the newly hired manager who acknowledged the log was inaccurate as facility staff failed to document whenever R1 had a bowel movement as they should.

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

Regarding to allegation of facility staff did not provide resident appropriate medical supplies, the reporting party stated that R1 performed blood sugar testing a few times a day and the facility staff did not provide R1 with alcohol wipes for the procedure instead, facility staff offered toilet paper or napkins as facility staff stated that they did not have any alcohol wipes available.

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

During the initial complaint visit on 4/20/2023, LPA observed facility did not have any alcohol wipes as house supplies instead staff provided 2 boxes of alcohol wipes with another resident's name it.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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According to staff, they did not provide alcohol wipes for R1 when R1 was performing blood sugar checks.

According to R1, staff instructed R1 to use toilet paper or baby wipes to sanitize R1's finger while doing blood sugar checks. R1 asked for alcohol wipes and R1 was told numerous times by facility staff that they did not have any.

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

Regarding to allegation of facility staff did not ensure that resident's hygiene needs are being met, the reporting party stated that R1 has not had a hair shampoo for 3 weeks, has not had a shave, and has not gotten assistance with brushing teeth.

As part of the investigation, LPA interviewed R1, newly hired manager, facility staff and reviewed documentation.

According to R1, R1 has not gotten a shower for many, many weeks instead R1 was provided with sponge baths daily. However, during sponge baths, they did not provide hair shampoo and in order for R1 to brush teeth and to shave, R1 had to request for it during the sponge baths. In addition, when R1 requested a hair shampoo, facility staff would agree to it and asked R1 to wait but often they forgot or claimed they were too busy to assist R1.

According to newly hired manager, shaving, shampooing hair and brushing teeth are routine tasks that should be performed as part of the sponge bath and there was no need for residents to request for it.

According to S2, R1 gets a sponge bath on a daily basis which did not include shaving, brushing teeth and shampooing hair unless it was requested by R1. However, S2 acknowledged that these tasks should be included and residents did not have to ask for it.

Based on R1's appraisal/needs and services plan, R1 required assistance with ADLs (Activities of Daily Living).

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

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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Regarding to allegation of- facility staff does not speak language that resident understands, the report party stated the caregivers always speak in their language in front of R1.

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

According to R1, facility staff always talked in a language that R1 did not understand which made R1 felt uncomfortable. R1 reminded staff to speak English while talking in front of R1 and they verbally agreed but they continued to talk in a language that R1 did not understand.

During the initial complaint visit on 4/20/2023, LPA observed 2 female staff speak in their language in front R1's door while R1 was in bed.

LPA interviewed other residents who stated that they have also experienced facility staff spoke in a language that they did not understand in front of them but it was not an issue for them.

After the investigation, this allegation is deemed to be substantiated as it did not bother the other residents but it made R1 felt uncomfortable.

Regarding to allegation of facility staff did not ensure that resident's food/drink are served at the right temperature, the reporting party stated that R1 received cold to lukewarm food every day such as cold boiled eggs, cold oatmeal twice a week and cold English muffin. In addition, R1 has told facility staff that R1 did not like receiving cold food items but R1 continued to get them.

As part of the investigation, LPA interviewed R1, other residents, newly hired manager and the administrator.

According to R1, the food is always served lukewarm or cold especially for breakfast. R1 expressed frustration with asking staff to heat it up on a daily basis and stated that the food quality was not the same after being in the microwave. R1 wanted the hot foods to be served hot.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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LPA interviewed other residents regarding to temperature of the food and they reported that sometimes it was cold and they had to ask staff to heat it up but that was not an issue for them. One of the residents stated the meals were being prepared ahead of time resulted temperature not being maintained.

LPA interviewed facility manager and administrator who acknowledged that breakfast is being cook too early, therefore, the temperature was not being maintained when served. Both of them stated that they will revisit the breakfast workflow and make adjustments to ensure residents are being served hot meals.

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

Based on interviews, observation and record reviews during the course of investigation, the preponderance of evidence standard has been met. Therefore, these 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 reviewed and discussed with manager, 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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 9 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87468.1(a)(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 have all of the following personal rights:..(2)To be accorded safe, healthful and comfortable accommodations,..	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure R1's care is being met and R1's appraisal/needs and service plan is followed by facility staff. This plan will include staff education.
	8 9 10 11 12 13 14	This requirment is not met as evidenced by facility did not ensure R1's room was ventilated, facility failed to get R1 up from the bed so R1 could enjoy fresh air and sunshine outside of R1's room; faciliy did not ensure R1 had cleaned and	8 9 10 11 12 13 14	The administrator/licensee and/or designee will provide a copy of this plan and a copy of facility staff in-service sign-in record to CCL by 7/14/2023.
Type B 07/14/2023 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	CONT... well fitted linens/beddings; facility failed to provide proper supply to R1 prior to R1 performing self blood sugar checks and R1 felt uncomfortable when staff conversing in front of R1 in a language that R1 did not understand, and facility left R1 in bed all the day long which posed	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	potential health risks to 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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 10 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General..a) Facility personnel shall at all times be sufficient..and competent to provide the services necessary to meet resident needs...This requirement is not met	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure facility staff is properly trained to use equipment that is required to care for residents. The plan needs to include when facility staff will be trained and who will be
	8 9 10 11 12 13 14	as evidenced by facility staff was not trained on how to use a hoyer lift resulted R1 not getting out of bed for many months which posed a potential risk for resident in care.	8 9 10 11 12 13 14	providing the training. The administrator/licensee and/or designee will provide a copy of the plan and a copy of the in-service sign-in record to CCL by 7/14/2023.
Type B 07/14/2023 Section Cited CCR 87217(b)	1 2 3 4 5 6 7	87217 Safeguards for Resident Cash, Personal Property, and Valuables..(b) Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure this does not happen again and the plan shall include staff education. The administrator/licensee shall provide a copy of the plan and a copy of the staff education sign-in
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by facility mistakenly handed R1's personal wheelchair to a equipment company when they came to pick up equipment for another resident which posed a potential risk for resident in care.	8 9 10 11 12 13 14	record to CCL by 7/14/2023.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 11 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 Section Cited CCR 87468.2(a)(19)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities,..(19) To have prompt access to review all of their records ...	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure this does not happen again and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by R1 requested to review R1's inventory list, however, it was not provided which poses a potential risk for resident in care.	8 9 10 11 12 13 14
Type B 07/14/2023 Section Cited CCR 87506(a)	1 2 3 4 5 6 7	87506 Resident Records.. a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility... This requirment is not met as evidenced by facility staff failed	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure facility staff complete resident's records accordingly and the plan shall include staff education.
	8 9 10 11 12 13 14	to complete R1's ADL log which poses a potential risk for resident in care.	8 9 10 11 12 13 14	Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 12 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/07/2023 Section Cited CCR 87465(h)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure medication storage is lock and inaccessible to residents in care and the plan shall include staff education.
	8 9 10 11 12 13 14	employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by during the 10-day complaint visit, LPA Han observed the medication storage in the kitchen was not locked and there were no staff present which poses an immediately risk to resident in care.	8 9 10 11 12 13 14	The administrator/licensee will submit a copy of the plan to CCL by 7/7/2023.
	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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 13 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/14/2023 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..	1 2 3 4 5 6 7	The administrator/licensee and/or designee will develop a plan to ensure this does not happen again and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility staff failed to provide R1 ADL care during bed bathes which poses a potential risk for resident in care.	8 9 10 11 12 13 14
Type B 07/14/2023 Section Cited CCR 87468.2(a)(5)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities..(a) In addition to the rights listed in Section 87468.1,..(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 this does not happen again and the plan shall include staff education. Facility will provide a copy of the plan and staff education sign-in sheet to CCL by 7/14/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility severed R1 cold meals which poses a potential 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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 14 of 19

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
04/14/2023 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20230414140716

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:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Manager, Oscar Madrigal		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility is odoriferous.
Facility staff does not respond to a resident's calls for assistance.

INVESTIGATION FINDINGS:

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On July 5, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230414140716. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit.

Regarding to allegation of facility is odoriferous, the reporting party stated that in room 3-4 the urine smell was atrocious.

As part of the investigation, LPA interviewed facility staff and conducted a tour of the facility.

LPA interviewed facility staff who acknowledged that room 3-4 has a strong urine smell at times and they attributed the smell to resident #2 (R2) who would urinate in bed, and became combative when they attempted to clean and to change him/her. However, they continued to try providing care.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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

LIC9099 (FAS) - (06/04)

Page: 15 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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During the initial visit, LPA observed a slight urine odor inside of R2's room but odorless by the hallway.

After the investigation, this allegation is deemed to be unsubstantiated as facility staff acknowledged that there was an odor smell at times, however, it was due to a resident who was refusing to be cleaned but they were encouraging resident to be compliant with care.

Regarding to facility staff does not respond to a resident's calls for assistance, there is no additional information forthcoming from the reporting party. However, R1 stated that R2 yelled and screamed at night and no one attended to R2.

As part of the investigation, LPA interviewed facility staff and observed R2.

During the initial complaint investigation on 4/20/2023, LPA observed R2 in bed, sleeping and when staff gently attempted to initiate a conversation, R2 became combative and agitated.

According to facility staff, R2 screamed and yelled on and off during the night and slept during the day. They also stated that they were aware that R2's behavior was disruptive to other residents such as R1. Therefore, they stayed close to R2's room during the night so they could monitor R2 closely.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 16 of 19

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
04/14/2023 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20230414140716

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:	07/05/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Manager, Oscar Madrigal		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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Facility staff did not seek resident medical attention for a skin condition.
Facility staff did not ensure that resident received their medication on a timely basis.
Facility staff did not notify resident of change in their room.

INVESTIGATION FINDINGS:

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On July 5, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230414140716. LPA met with manager, Oscar Madrigal and explained the purpose to today's visit.

Regarding to allegation of facility staff did not seek medical attention for resident skin condition, the reporting party stated that resident #1 (R1) reported of having some kind of rash on the buttocks.

As part of investigation, LPA interviewed facility staff, the former assistant administrator and R1.

LPA interviewed R1 who reported being hospitalized in March 2022 for skin condition and upon returned, R1 received wound treatment from a home health agency until the wound was healed. R1 reported that currently R1 does not have any skin conditions.

Unfounded

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

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

LIC9099 (FAS) - (06/04)

Page: 17 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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LPA interviewed facility staff who reported that currently R1 does not have any skin rashes and they apply cream to prevent rashes and other skin conditions.

LPA interviewed the former assistant administrator who stated that R1's pressure ulcer and rashes were treated by a home health agency until healed.

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

Regarding to allegation of- facility staff did not ensure that resident received their medication on a timely basis, there is no additional information forthcoming from the reporting party.

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

R1 stated sometimes the medication was given late but R1 was not able to provide additional details.

LPA interviewed facility staff and they reported that they administered R1's medication on time.

LPA interviewed 3 residents and all of them reported that their medication(s) arrived on time and they had no concerns.

LPA observed the medication administration records to be adequate.

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

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 18 of 19

Control Number 14-AS-20230414140716

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: 07/05/2023

NARRATIVE

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Regarding to allegation of facility staff did not notify resident change of room- during the initial reporting, the reporting party stated that R1 was hospitalized in March 2023 and when R1 returned, R1 was moved to a small room and unventilated.

As part of the investigation, LPA interviewed R1, facility staff, former assistant administrator, and administrator.

LPA interviewed R1 who provided the same details as the reporting party but clarified that the hospitalization was in 2022 and not 2023. R1 was not able provide the room number and/or the location of the room that R1 has resided prior to the hospitalization.

LPA interviewed 6 facility staff including one of them who has been employed prior to R1's admission and all of them stated that R1 was not moved to a different room after being hospitalized in 2022.

LPA interviewed the administrator and the former assistant administrator and both of them denied the allegation and stated that R1 returned to the same room after R1's hospital stay in 2022.

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

This agency has investigated these complaints and we have found that the complaints were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed.

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: 07/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023

LIC9099 (FAS) - (06/04)

Page: 19 of 19