Community Care Licensing

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On 10/20/2022 Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220930104518. LPA met with the administrator and explained the purpose of the visit. During the course of the investigation, the allegations of staff are not following resident's Admissions Agreement and Resident's Representative did not receive a copy of the Admissions Agreement, the facility was not able to provide R1's admission agreement to LPA for review as staff #1 (S1) stated that R1's admission agreement is maintained with the former facility manager and not at the facility. Based on the complaint investigation, the facility did not ensure R1's current record is maintained in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator. A copy of this report and the Appeal Rights are provided.

SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022

Document Has Been Signed on 10/20/2022 07:58 PM - It Cannot Be Edited

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/03/2022 Section Cited	1 2 3 4 5 6 7	87506 Resident Records(a)The licensee shall ensure...a current record is maintained for each resident in the facility.. readily available to facility staff and to licensing agency staff..(b) Each resident’s record shall contain..
	8 9 10 11 12 13 14	(15)The admission agreement.. This requirement is not met as evidenced by: the facility did not have resident #1 (R1)'s admission agreement in the facility which poses a potential health risk to residents in care.	8 9 10 11 12 13 14
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SUPERVISOR'S NAME: Cara Smith TELEPHONE: (650) 266-8800 LICENSING EVALUATOR NAME: Murial Han TELEPHONE: (619) 209-9761 LICENSING EVALUATOR SIGNATURE: DATE: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/20/2022