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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601097
Report Date: 10/20/2022
Date Signed: 10/20/2022 12:29:41 PM


Document Has Been Signed on 10/20/2022 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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:
(415) 571-8531
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:14CENSUS: 13DATE:
10/20/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
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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-20220914194759. LPA met with the administrator and explained the purpose of the visit.

During the course of the investigation, the allegation of resident sustained pressure injuries while in care was unsubstantiated, however, LPA observed resident #1 (R1) and resident #2 (R2) were in a hospital bed with 2 half bed rails up by the head of the bed and according to staff #1 (S1), this device is used to assist R1 and R2's mobility in bed. However, the facility was not able to provide a written physician's order for such device for R1 and R2.

Based on documents provided, the bed rails for R1 and R2 were not addressed in the appraisal /needs and service plans. Furthermore, the appraisal / needs and service plans for R1 and R2 were not signed by R1 and R2 and/or their responsible party(s) indicating that they reviewed and agreed with the service plans.

In addition, during the course of the complaint investigation, R1 expressed satisfaction with the services that was provided by the home health visiting nurse, however, R1 was pressured by facility staff to discontinue the services by this visiting nurse as R1 was told by the facility staff that the visiting nurse did not properly follow through with R1's physician on R1's medication but R1 disagreed.

Based on complaint investigation, 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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/20/2022 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


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 A
10/24/2022
Section Cited

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ยง1569.80 Care and services decision making; meeting; written record a) A resident of a residential care facility for the elderly, or the resident's representative, or both, shall have the right to participate in decision making regarding the care and services to be provided to the resident.
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This requirement is not met as evidenced by: R1 is satisfied with services that was provided by the home health visiting nurse. However the facility pressured R1 discontinuing the services from this visting nurse which posed an immediately health risks to resident in care.
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The administrator will provide in-services to staff on this regulation.
The administrator will inform CCL in writing of R1's decision and will submit a copy of the in-service record to CCL by the plan of correction due date 10/24/22.
Type B
11/03/2022
Section Cited

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87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: during the 10-day
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initial complaint visit, LPA observed R1 and R2 have half bed rails up by the head of their beds, however, the need of utilzing this device was not reflected in their appraisal needs which poses a potential health risk to residents in care
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The administrator will submit a copy of all the updated appraisal/ needs and services plan to CCL by the plan of correction due date of 11/3/2022.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/20/2022 12:29 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


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

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support...
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This requirement is not met as evidence by: R1 and R2 have half bed rails by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.
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postural supports and if one is being used, the facility will obtain a physician's order indicating the need for the device that is being used.
The administrator will provide a copy of the in-service and a copy of all the physician's order obtained to CCL by the plan of correction due date 11/3/2022.
Type B
11/03/2022
Section Cited

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87457 Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed..(3) The prospective resident, or his/her responsible person,...shall be involved in the development of the appraisal.
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This requirement is not met as evidenced by R1 and R2's appraisal needs/service plans were not signed indicating it's reviewed and agreed by the residents and/or their responsible parties which poses a potential health risk to residents in care.
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The administrator will provide a copy of all the completed residents appraisals and service plans and a copy of the above plan to CCL by the plan of correction due date 11/3/2022.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (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
LIC809 (FAS) - (06/04)
Page: 3 of 3