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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601116
Report Date: 05/21/2025
Date Signed: 05/21/2025 12:12:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/06/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250306100512
FACILITY NAME:COTERIE CATHEDRAL HILLFACILITY NUMBER:
385601116
ADMINISTRATOR:DEBORAH SUAREZFACILITY TYPE:
740
ADDRESS:1001 VAN NESS AVENUETELEPHONE:
(415) 915-6615
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:260CENSUS: DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Matt Turner, Executive DirectorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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Staff did not ensure that medications are inaccessible to residents in care
INVESTIGATION FINDINGS:
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On 5/21/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Matt Turner. LPA toured the facility, interviewed residents, reviewed records, gathered photos and made observations during the course of the investigation.

Complaint alleges, staff did not ensure that medications are inaccessible to residents in care. Based upon a review of resident's (R1) medical assessments from 2023 and 2024, it is determined that R1 is not able to manage or store their own medications. In addition, LPA gathered photo evidence showing multiple prescription medications left by staff in R1's bedroom on separate occasions.

Allegation, above is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
03/06/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250306100512

FACILITY NAME:COTERIE CATHEDRAL HILLFACILITY NUMBER:
385601116
ADMINISTRATOR:DEBORAH SUAREZFACILITY TYPE:
740
ADDRESS:1001 VAN NESS AVENUETELEPHONE:
(415) 915-6615
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:260CENSUS: DATE:
05/21/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Matt Turner, Executive DirectorTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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9
Staff did not administer medication as prescribed
Staff did not properly manage resident's medication
INVESTIGATION FINDINGS:
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On 5/21/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Matt Turner. LPA toured the facility, interviewed residents, reviewed records, gathered photos and made observations during the course of the investigation.

Complaint alleges, staff did not properly manage resident's medication regarding records. Based upon review of resident (R1) records, LPA found that the facility utilizes an electronic medication administration record (MAR) that staff utilize to track medication dosages for residents. Upon a sample review of R1's MAR, LPA did not find enough corroborating evidence indicating the failure to utilize or mismanage R1's medication records.

Continued onto LIC9099-C


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20250306100512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: COTERIE CATHEDRAL HILL
FACILITY NUMBER: 385601116
VISIT DATE: 05/21/2025
NARRATIVE
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Complaint alleges, staff did not administer medication as prescribed. Complaint further indicates that R1 is given an eye drop medication more than the daily prescribed dose. Based upon a review of R1's medication records, LPA found that R1 is prescribed two different eye drop medications, both of which have orders for daily use. One of which is administered once per day and the other administered three times per day. Photo evidence shows that the eye drop medication with an order to administer once per day was left accessible in R1's bedroom. However, based upon sample review of R1's MAR, LPA did not find enough corroborating evidence indicating the facility had incorrectly or over-administered R1's medication. In addition, interview with R1 posed contradicting information towards the allegation.

A finding that the complaint allegations, staff did not administer medication as prescribed and staff did not properly manage resident's medication are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiency cited.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20250306100512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: COTERIE CATHEDRAL HILL
FACILITY NUMBER: 385601116
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/22/2025
Section Cited
CCR
87465(h)(2)
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87465(h)(2) - Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This was not met as evidence by:** Based upon review of resident R1 records,
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Licensee/Administrator failed to ensure R1's medications were kept safe and not accessible to residents in care. Licensee agrees to conduct a training on protocols for medication storage and administration. Scheduled training date to be submitted to CCLD by POC date 5/22/2025. In addition,
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LPA found that resident R1 is not able to manage or store their own medicaitons. Additionally, gathered photo evidence shows prescription medicaiton left in R1's bedroom by staff on multiple occassions. This serves as an immediate health & safety risk to resident in care.
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completed training signed by all participating staff is to be submitted to CCLD by POC date 5/30/2025.
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4