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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 06/07/2021
Date Signed: 06/07/2021 03:26:53 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/18/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210518142918
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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Juliet PacaldoTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility is in disrepair
INVESTIGATION FINDINGS:
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On 6/7/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up complaint investigation. LPA met with the Administrator, explained the purpose of the visit and delivered the findings to the allegations.

Regarding to facility is in disrepair, on 5/28/2021, during the facility tour, LPA checked several faucets in the facility and all of them were in good working condition. LPA also checked multiple linens/towels in the laundry room and resident's beds. The inspection on the resident's room found the following: resident 1 (R1)'s room has sawdust on top the baseboard that was behind R1's bed, one of the windows is cracked with spider web on the right corner. Facility staff acknowledge awareness of the cracked window for 2-3 months, and someone had come to the facility 2 or 3 days ago obtaining measurements for R1's window and another window on the 2nd floor in order to either fix or replace the windows.

Continues onto LIC9099C
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 14-AS-20210518142918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/07/2021
NARRATIVE
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At 12:00pm, LPA observed the laundry room sink has a brush that was placed on top of gray dust and hair. The washer has hair and black dust under the cover on the right corner and dryer has black dust on top and in between the lid.

At 12:05PM, LPA observed bathroom #1 on the 1st floor has white partials on top of the faucet, white dirt around the sink, a tooth brush inside of a plastic cup on the right side of the sink and an open pack of toothache brushes on the left side of the sink.

At 12:15PM, LPA observed bathroom #2's faucet has orange and rusty stains.

The staff member acknowledged the above observations and reported that it was the night Shift's responsibility to clean the bathrooms and other parts of the facility.

At 2:15PM, LPA spoke to the Administrator via phone regarding the above findings and the Administrator stated that it was shocking to identify the above conditions as all the staff members were supposed to clean it daily and after each use.

Based on observation and interviews, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated.

This deficiency is cited in accordance with CA Code of Regulations, Title 22 are cited on the attached LIC 9099-D.

Exit interview was conducted with the Administrator, Juliet Pacaldo and Appeal Rights were given.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20210518142918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
06/21/2021
Section Cited
CCR
87307(d)(2)
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PERSONAL ACCOMMODATIONS AND SERVICES
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment. This requirement is not met: Based on observation and interview,
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Licensee/administrator agreed to submit a written plan of action to CCLD by POC due date.
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LPA observed the following during the inspection: A resident (R1)'s room has sawdust on top of the baseboard, one of the windows is cracked and had a spider web, laundry room sink has a brush that was placed on top of a gray dust and hair. The washer has hair and black dust under the cover on the right corner
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Type B
06/21/2021
Section Cited
CCR
87307(d)(2)
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Cont) and the dryer has black dust on top and in between the lid. Bathroom #1 on the 1st floor has white partials on top of the faucet, white dirt around the sink, a tooth brush inside a plastic cup on the right side of the sink and an open pack of toothache brushes on the other
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side; bathroom 2 's faucet has orange and rusty stains which poses a potential risk to client 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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
05/18/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210518142918

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
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator, Juliet pacaldoTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility failing to follow the dietary needs of the resident
Facility is not managing resident incontinence
INVESTIGATION FINDINGS:
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On 6/7/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up complaint investigation. LPA met with the Administrator, Juliet Pacaldo explained the purpose of the visit and delivered the findings to the allegations.

Regarding the allegation the facility failing to follow the dietary needs of the resident, Reporting Party states that Resident 1 (R1) is diabetic and the facility serves sugary desserts and high salt. The facility staff stated that is aware that R1 is diabetic and the facility is buying the groceries according to the food preference list that was provided by R1.

R1 stated who stated that a list of food preference of "likes" and "dis-likes" was shared with the staff and they follow it most of the time and If they don't, R1 would not eat it and would send it back. Staff stated that resident would asks at times for dessert and other sugary items, and staff does its best to avoid feeding the resident such food.

LPA reviewed R1's Physician's Reported dated 2/16/2021 which does not indicate R1 requires a special diet. In addition, the Preplacement Appraisal Information was marked "No" under Special diet/observation of food intake section. This appraisal was signed and acknowledged by the Responsible Party.


This report is continued on LIC 9099C
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20210518142918
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 06/07/2021
NARRATIVE
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Regarding to facility not managing resident incontinence, the Reporting Party stated that R1 was sitting in soiled diaper for 25 hours, however, the staff members denied this allegation. The day shift staff reported that R1 is being changed every 4-5 hours and whenever is needed in between. The night shift staff reported that R1 is being changed once per night and R1 would get angry if being bothered too many times for changes during the night. LPA also interviewed the witness who stated that R1 was not soiled during the visit.

Based on the above information, interviews, and record during this investigation, it was determined that although the above allegations 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 allegations are deemed UNSUBSTANTIATED at this time.

This report was discussed and reviewed with the Administrator and a copy is 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5