385601097-10-20-2022-14-AS-KHOS-CKSLKM-20221102084945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601097
Report Date: 10/20/2022
Date Signed: 10/20/2022 12:44:27 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
09/14/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220914194750

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		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Staff yell at resident in care.
Staff do not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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On 10/20/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220914194750. LPA met with the administrator and explained the purpose to today's visit.

Regarding to allegation of staff yelled at resident in care, the reporting party stated that staff yelled at resident #1 (R1) on several occasions and it was witnessed by the reporting party.

As part of the investigation, LPA interviewed R1 who stated that there is one staff (staff #1) yelled at R1 and other residents if they did not comply with S1's instructions.

LPA also interviewed other residents and according to resident #2 (R2), S1 has yelled at R2 as well.

In addition, LPA interviewed S1 who acknowledged of yelling back at residents when residents became repeatedly disrespectful to S1.

Furthermore, LPA interviewed the former facility manager who also acknowledged S1's behavior and stated that the facility has been addressing S1's inappropriate behavior both in verbal and in written.

After the investigation, the above allegation is deemed to be substantiated.

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 6

Control Number 14-AS-20220914194750

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

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Regarding to the allegation of staff do not treat resident with dignity and respect, in addition to staff yelled at R1, R1 stated that when R1 was hospitalized, facility staff moved R1's belongings without R1's presence and permission.

As part of the investigation, LPA interviewed S1 who acknowledged that staff moved and cleaned R1's belongings while R1 was out of the facility as R1's room was too cluttered.

During LPA's 10-day complaint inspection, LPA observed R1's personal belongings were displaced from R1's room without R1's consent. After the investigation, this allegation is substantiated.

Based on interviews and observations during the course of the investigation, the preponderance of evidence standard has been met. Therefore, these 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.

This report is discussed with Administrator and a copy of is provided including the Appeal Rights.

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 6

Control Number 14-AS-20220914194750

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 A 10/24/2022 Section Cited CCR 87413(a)(2)	1 2 3 4 5 6 7	87413 Personnel - Operations (a) In each facility:(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice.	1 2 3 4 5 6 7	The administrator and the licensee will develop a plan of correction to ensure residents are not being verbally abused during care and supervision. The plan needs to illustrate the steps that the facility will take to monitor that this behavior does not happen again.
	8 9 10 11 12 13 14	The requirement is not met as evidenced by: staff #1 (S1) yelled at residents during care and supervision which poses an immediate health risks to residents in care.	8 9 10 11 12 13 14	In addition, the administrator will provide in-services to staff to prevent abuse from happening again. The facility will submit a copy of the plan and in-service sign-in record to CCL by the plan of correction due date 10/24/22.
Type B 11/03/2022 Section Cited CCR 87468.2(a)(1)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...(1) To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator will provide in-service to staff - Rights of Residents and Privacy and provide a copy of the sign-in record to CCL by 11/3/2022.
	8 9 10 11 12 13 14	The facility moved and displaced resident #1's personal belongings from R1's room without R1's presence, and consent which poses a potential health risks for resident 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: 3 of 6

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
09/14/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20220914194750

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		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

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Resident sustained pressure injuries while in care.
Resident developed a rash while in care.
Resident is not properly bathed while in care.

INVESTIGATION FINDINGS:

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On 10/20/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220914194750. LPA met with administrator and explained the purpose to today's visit.

Concerning to allegation of resident sustained pressure injuries while in care, the reporting party stated that resident #1 (R1) is high risk of developing pressure injuries due to R1's physical condition and R1's pressure injury was healed.

As part of the investigation, LPA interviewed facility staff and former facility manager and both of them reported that R1's pressure ulcer has been healed. They also stated that R1 is high risk for pressure ulcers due to R1's limited physical mobility and R1 has had episodes of refusing to be turned and repositioned. Therefore, R1 has a special pressure relieving mattress as a prevention.

Unsubstantiated

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: 4 of 6

Control Number 14-AS-20220914194750

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

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During the 10-day complaint visit, LPA observed R1 was lying on a hospital bed with a special pressure relieving mattress, and 2 half bedrails up by the head of the hospital bed.

Based on the documents provided, LPA observed the dates and times when R1 refused to be turned and repositioned by staff.

Base on record review, observations, and interviews during the course of investigation, this allegation is unsubstantiated as the facility provided actions to prevent R1 from developing pressure injuries including making referral to a home health agency for wound management and obtaining a special mattress for relieving pressure but due to R1's health condition, R1 developed pressure ulcer and it was healed.

Although the above allegation is deemed to be unsubstantiated, the facility was not able to provide a written order from the physician for the half bedrails, therefore, this finding will be cited on a LIC 809 and LIC809D under Postural Supports.

Regarding to resident developed a rash while in care, the reporting party stated that R1 developed a rash due to the plastic ties from the adult brief were too tight around R1's stomach.

As part of the investigation, LPA interviewed R1 who did not express any concerns regarding to staff placing the adult brief too tight and R1 was not aware of a rash developed around R1's stomach.

LPA interviewed staff who stated that they knew not to place the audit brief too tight on R1 and they left one plastic tie untied. LPA observed R1 and validated this practice.

Based on interviews and observations during the course of the investigation, this allegation is deemed to be unsubstantiated.

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: 5 of 6

Control Number 14-AS-20220914194750

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

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Regarding to resident is not properly bathed while in care, the reporting party stated that facility staff often do not rinse the soap off of R1 thoroughly after a bed bath.

As part of the investigation, LPA interviewed the former facility manager who denied the allegation and stated that facility has recently switched from regular soap to a no-rinse bathing wipes for bed baths. Therefore, there was no rinse-off needed and it would be normal for a resident to feel the mild cleaning solution that is contained on the wipes after the bed bath.

LPA interviewed R1 who stated that the facility staff was providing unsatisfactory bed baths as staff did not rinse R1 thoroughly as R1 continued to have the slippery sensation on the skin after the bed baths.

LPA interviewed resident #2 (R2) and resident #3 (R3) who also received bed baths from staff and both of them reported that they were satisfied with the bed baths that they were provided.

Based on interviews and observations, this allegation is deemed to be unsubstantiated. Facility staff has explained to R1 of the no-rinse bathing wipes and agreed to go back to soap if R1 prefers.

Although the above investigations 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 allegation is UNSUBSTANTIATED.

This report is discussed and reviewed with the administrator.

A copy is 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)

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