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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601116
Report Date: 03/30/2022
Date Signed: 03/30/2022 12:17:54 PM


Document Has Been Signed on 03/30/2022 12:17 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:COTERIE CATHEDRAL HILLFACILITY NUMBER:
385601116
ADMINISTRATOR:LALOYAN,SIRUN SARAHFACILITY TYPE:
740
ADDRESS:1001 VAN NESS AVENUETELEPHONE:
(415) 915-6615
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:260CENSUS: 14DATE:
03/30/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jen Johnson, National Care Director and Shirley Cheung, Care Coordinator DirectorTIME COMPLETED:
12:30 PM
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On 3/30/2022 Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management inspection regarding to a self reported incident that was reported to CCLD on 3/28/2022. LPA Han met with the National Care Director, Jen Johnson, Care Coordinator Director, Shirley Cheung and the administrator, Sarah Laloyan join the inspection shortly after.

On 3/28/2022. the facility reported that concierge witnessed resident #1 (R1) was leaving the facility. R1 was wearing a device that alerted facility staff that he/she has left the facility. Therefore, staff #1 (S1) followed R1 out of the facility and staff #2 (S2) met up with them shortly a few blocks away from the facility and both staff escorted R1 back to the facility safely. Staff stated that there was no injuries noted to R1.

During today visit, LPA gathered the following information and documents: Physician report, appraisal needs and services plan, and documentation of resident's check status. LPA also interviewed the concierge on duty, the National Care Director and the Care Coordinator Director.

This incident needs further follow-up as LPA requested for additional documents to be submitted to CCL by 4/4/2022 and additional staff interviews.

Additional documents requested:
- Staff Training Records
- Revised LIC 624 (Unusual Incident/Injury Report)
- Documentation of the incident

This report is reviewed and discussed with administrator.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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