385601097-10-20-2022-14-AS-CSMH-CKQV5Y-20221031160842

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 10/20/2022
Date Signed: 10/20/2022 08:07:45 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
09/30/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220930104518

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: 13	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Juliet Pacaldo		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not following resident's Admissions Agreement.
Resident's Representative did not receive a copy of their Admissions Agreement.
Staff are not responding to Resident's Representative's requests for communication in a timely manner.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/20/2022. Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220930104518. LPA met with the administrator, Juliet Pacaldo and explained the purpose to today's visit.

Regarding to allegations of- staff are not following resident's admission agreement, and staff are not responding to Resident's Representative's requests of communication in a timely fashion, there was no additional information forthcoming from the reporting party. However, after speaking to the family member of resident #1 (R1), both allegations were pertaining to the unused portion of the monthly fee for R1 that has yet been refunded to the responsible party per the admission agreement.

According to the family member, R1 stayed at the facility for a few days in January, 2022 and passed away, the facility did not follow the admission agreement pertaining to its refund policy and the former facility manager did not provide a closure to the communication exchanges as the former facility manager agreed to refund the unused portion of the monthly fee to R1's responsible party but it has not been done.

Substantiated

Estimated Days of Completion:

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

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 4

Control Number 14-AS-20220930104518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/20/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

As part of the investigation, LPA requested for a copy of R1's admission agreement and the facility was not able to provide it. According to the staff #1 (S1), the facility did not have a copy of the admission agreement on file and the former facility manager has it. This is a deficiency and will be cited on LIC 809 under Admission Agreement as the facility shall retain the original signed and dated admission agreement in resident's file.

LPA interviewed the former facility manager who acknowledged that the facility has yet refunded the unused portion of the payment to R1's responsible party as the facility has made several attempts to refund R1's remaining balance to R1's responsible party but there was no success. The former facility manager agreed to provide written communication to CCL to show that attempts were made for the refund and a copy of R1's signed admission agreement. However, CCL has not received any documents from the former facility manager.

Based on the facility's standardized admission agreement, it states that refund would be issued in 30 days following the effective termination date.

Based on interviews and documents provided, this allegation is deemed substantiated as R1 passed away in January 2022 and the refund of the unused portion of the payment for January 2022 has not been issued and received by the responsible party.

Regarding to allegation of- resident's representative did not received a copy of the admission agreement, according to the family member, R1's responsible party signed some admission paper work and requested for a copy of the signed documents several times but has yet received it.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20220930104518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 10/20/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

As part of the investigation, LPA interviewed the former facility manager who stated that a copy of the admission agreement was emailed to the responsible party and will provide a copy to CCL. However, this information was not provided.. After the investigation, this allegation is deemed substantiated as the facility was not able to provide proof that a copy of the signed and dated admission agreement and all subsequent signed and dated modifications, to the resident or the resident's representative.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator, a copy is provided and Appeal Rights 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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20220930104518

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 10/27/2022 Section Cited CCR 1569.652(c)	1 2 3 4 5 6 7	§1569.652 Termination of admission agreement upon death of resident;...(c) A refund of any fees paid in advance....within 15 days after the personal property is removed. This requirement is not met as evidence by:	1 2 3 4 5 6 7	The Administrator and/or Licensee will refund the unused balance to R1's responsible party by 10/27/2022.
	8 9 10 11 12 13 14	In January 2022, R1 stayed at the facility for a few days and the responsible party paid for the entire month but the facility has yet refunded the unused portion of the payment to the RP poses a potential risk to person(s) in care.	8 9 10 11 12 13 14	The Administrator and/or Licensee will review the regulation and provide a signed written statement after the review and submit it to CCL by the plan of correction due date 10/27/2022.
Type B 11/03/2022 Section Cited CCR 87507(e)	1 2 3 4 5 6 7	87507 Admission Agreements..(e) The licensee shall provide a copy of the signed and dated current admission agreement,..to the resident or the resident's representative, The requirment is not met as evidenced by:	1 2 3 4 5 6 7	The Administrator and/or Licensee will review the regulation and provide a signed written statement of acknowledgement of the review and the administrator and/or the licensee will submit a plan to ensure compliance by the plan of correction due date 11/3/2022.
	8 9 10 11 12 13 14	The facility did not provide a copy R1's admission agreement to R1's responsible party despite R1's responsible party's requests which poses a potential risk to person(s) in care.	8 9 10 11 12 13 14

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 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

LIC9099 (FAS) - (06/04)

Page: 4 of 4