385601097-7-25-2024-14-AS-ACON-D8SM7C-20240904092115

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 07/25/2024
Date Signed: 07/25/2024 07:54:51 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
09/22/2023 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230922090634

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: 8	DATE:	07/25/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Shirley Aguado and Julio Yap		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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- Facility grounds are unkept and full of debris
- Staff does not ensure that resident's room is ventilated

INVESTIGATION FINDINGS:

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Based on observations made on 10/2/23 during initial complaint visit, this allegation is substantiated. The preponderance of evidence standard has been met.

In backyard, a mattress covered with a ripped mattress cover was observed on top of a patio table and chairs, a plush blanket was draped over a hedge, two wheelchairs were stored under stairs, and numerous empty cardboard boxes were scattered.
In addition, boxes, filled plastic bags, tables and overgrowth of plants obstructed the ground level passageway leading from street to backyard. See Facility Evaluation Report of 10/2/23 for Type B deficiency cited.
Front room on ground floor was created by construction of wall in bedroom. Wall has since been removed after citation issued on 10/2/23; see Facility Evaluation Report. The small front room formed by the wall had no window.

Deficiency of the California Code of Regulations, Title 22 is cited on a following page.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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)

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Control Number 14-AS-20230922090634

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 B 08/08/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	MAINTENANCE AND OPERATION The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Administrator to submit plan of correction BY DUE DATE to ensure that grounds are at all times free of debris and accessible to residents, staff and visitors
	8 9 10 11 12 13 14	This requirement was not met, as licensee failed to ensure that backyard and access to backyard are free of debris. This posed a potential health, safety or personal rights risk to clients 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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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 5

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
09/22/2023 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20230922090634

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: 8	DATE:	07/25/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Shirley Aguado and Julio Yap		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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- Staff leaves resident(s) in bed all day
- Staff does not assist residents when they yell and scream for help
- Facility is in disrepair
- Facility does not have sufficient night staff to implement Hoyer transfers
- Staff does not ensure that resident has privacy in their room
- Staff does not properly handle the residents' soiled bedding

INVESTIGATION FINDINGS:

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Based on observations and interviews with staff, these allegations are determined to be unsubstantiated.
Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

On 10/2/23 and today, LPA Jeung observed 2 residents who tend to stay in bed for prolonged periods of time out of bed. On 10/2/23, male client is seated in wheelchair in front of facility. Today, female client is seated in wheelchair in her room.
Staff were interviewed and confirmed that 2 clients would yell and scream. When they responded, clients were provided with assistance or food or drinks. Both clients are no longer residents.
On 10/2/23, LPA observed a ceiling fixture in front room on ground floor that was not flush with ceiling. It did not appear to pose a health risk. The light was operable.

Continued on next page.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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 5

Control Number 14-AS-20230922090634

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
	VISIT DATE: 07/25/2024

NARRATIVE

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Based on staffing schedules observed when complaint investigation was initiated, it could not be determined that night staff was sufficient. However, LPA observed documentation of hoyer lift training for 4 staff.
Pertaining to client's privacy, it was acknowledged by client during interview that bedroom door is often left open. He stated that this was not a concern.
During previous complaint visit, bed linens were observed draped on foliage in backyard to be aired out. Staff were advised that this practice is not appropriate. According to staff, laundry is done daily and clothes washer and dryer are operable.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
09/22/2023 and conducted by Evaluator Audrey Jeung

COMPLAINT CONTROL NUMBER: 14-AS-20230922090634

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: 8	DATE:	07/25/2024
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Shirley Aguado and Julio Yap		TIME COMPLETED:	08:00 PM

ALLEGATION(S):

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- Facility does not provide a safe environment for the residents

INVESTIGATION FINDINGS:

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The complaint alleging that facility is not safe 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.

Safety concerns that client with hearing impairment would be unable to hear fire alarm unless it is in his bedroom is unrealistic and unwarranted. Staff are responsible for ensuring safety of clients in the event of a fire emergency.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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: 5 of 5