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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601097
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:36:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SUTRO HEIGHTS CORPORATIONFACILITY NUMBER:
385601097
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:659 45TH STREETTELEPHONE:
(650) 393-0265
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:14CENSUS: 8DATE:
06/07/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Juliet PacaldoTIME COMPLETED:
03:45 PM
NARRATIVE
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On 6/7/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced inspection and met with the Administrator, Juliet Pacaldo. LPA explained the purpose of the visit and delivered this finding.

The information collected by LPA during the investigation of Complaint Control Number 14-AS-202105181 42918 shows that the facility was working on Resident 1 (R1)'s diet needs and incontinent needs however, the facility failed to develop an appropriate written care plan and appraisal. Furthermore, R1 was admitted to the facility under Hospice care, when R1 was discharged from hospice care, the facility failed to update the care plan and to reappraise the resident to reflect the changes needed.

Based on records review, and interviews, the preponderance of evidence has been met. Deficiency was cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 809-D. Report was discussed with administrator. A copy of this report and licensee’s Appeal Rights forms given to administrator. Appeals must be directed to Licensing Regional Manager.

This report was reviewed with Administrator and a copy of the report was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: SUTRO HEIGHTS CORPORATION
FACILITY NUMBER: 385601097
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2021
Section Cited

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RESIDENT RECORDS
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by:
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Based on records review and interview, the Administrator did not ensure Resident 1's (R1) appraisal and service plan reflect the current health statues and needs including but not limiting incontinence care and dietary needs which poses an potential Health and Safety risk to persons 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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2021
LIC809 (FAS) - (06/04)
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