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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 07/25/2024
Date Signed: 07/25/2024 07:12:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
08/17/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230817153442
FACILITY NAME:SUTRO HEIGHTS CORPORATIONFACILITY NUMBER:
385601097
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:659 45TH STREETTELEPHONE:
(415) 571-8531
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:14CENSUS: 8DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shirley Aguado and Julio YapTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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- Staff are not providing medications as prescribed to resident(s) in care
INVESTIGATION FINDINGS:
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13
Based on observations by medical professional and review of medication records, this allegation is substantiated. The preponderance of evidence standard has been met.

Client #1 was prescribed Cephalexin on 8/8/23 but facility failed to obtain the antibiotic medication because the client did not pick it up. Staff did not make arrangements to pick up or have antibiotic delivered until 7 days later. In addition, Olodaterol/tiotropium inhaler was not refilled, as staff was observed giving client the inhalation device without the medication cartridge installed.

Deficiency of the California Code of REgulations, Title 22 is cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
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 3
Control Number 14-AS-20230817153442
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION
FACILITY NUMBER: 385601097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87465(a)(4)
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INCIDENTAL MEDICAL CARE
The licensee shall assist residents with self-administered medications as needed.
This requirement was not met, as staff failed to obtain antibiotic prescribed to client #1 on 8/8/23 in a timely manner. Licensee failed to ensure that client received Rx medication
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Plan/proof of correction to address timely administration of prescribed medications will be submitted to CCLD BY DUE DATE
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when prescribed, which posed an immediate health, safety or personal rights risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
08/17/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230817153442

FACILITY NAME:SUTRO HEIGHTS CORPORATIONFACILITY NUMBER:
385601097
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:659 45TH STREETTELEPHONE:
(415) 571-8531
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:14CENSUS: 8DATE:
07/25/2024
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shirley Aguado and Julio YapTIME COMPLETED:
07:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff does not ensure residents records are properly maintained
INVESTIGATION FINDINGS:
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13
The complaint alleging that medication records are not properly maintained has been investigated by the Community Care Licensing Division of the CA Department of Social Services, and determined to be unfounded. This means that the allegation could not have happened and/or is without a reasonable basis.

LPA Jeung reviewed medication records for client #1 and interviewed staff. Complainant alleged that medication administration record was not accurate. However, this is not required per Title 22 RCFE regulations, unless specifically requested by prescribing physician or licensing agency.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3