385601116-4-1-2026-14-AS-BCHN-DT29MQ-20260410232951

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601116
Report Date: 04/01/2026
Date Signed: 04/01/2026 02:34:39 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
12/30/2025 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20251230164609

FACILITY NAME:	COTERIE CATHEDRAL HILL		FACILITY NUMBER:	385601116
ADMINISTRATOR:	MATTHEW TURNER		FACILITY TYPE:	740
ADDRESS:	1001 VAN NESS AVENUE		TELEPHONE:	(415) 915-6615
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	260	CENSUS: 223	DATE:	04/01/2026
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator, Matthew Turner		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent a resident from hitting another resident in care.

INVESTIGATION FINDINGS:

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

On April 1, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint findings. LPA met with administrator and the assistant general manager, Deborah Suarez and LPA explained the purpose of today's visit.

Regarding the allegation of, staff did not prevent a resident from hitting another resident in care- the reporting party stated that resident in question (R1) was hit in the head by resident #2 (R2) in the dining room. R1 stated that this incident was witnessed by the manager and the manager asked R2 to leave the dining room.

As part of the investigation, LPA interviewed R1, R1’s responsible party, R2, resident #3 (R3), administrator, and facility directors.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

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-20251230164609

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: 04/01/2026

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

LPA interviewed the administrator who stated that prior to the dining room incident, there were reports that R2 was calling R1 names but there were no incidents of physical abuse. The administrator acknowledged that there was an incident that happened in the dining room where R2 was yelling at R4 but it was not reported that R4 was hit and due to R4’s diagnosis, it was unclear whether he/she was hit. In addition, the administrator stated that initially R4's responsible party reported that R4 was not hit but subsequently reported being hit. The administrator stated that after R2 hit R1, the facility issued a 30-day discharge notice to R2 and R2’s responsible party to ensure the safety of R2 and the other residents at the facility.

Regarding the one-to-one caregiver who was not present during the incident, the administrator stated that this person was hired by R2’s responsible party to ensure R2 did not leave the facility unsupervised due to R2's diagnosis. The administrator stated that on the day of the incident, the private caregiver was sitting in a room monitoring the elevators and did not have a line of sight to the dining room when the incident occurred.

After the investigation, this allegation is substantiated. Based on interviews and record reviews, the facility did not prevent this incident from occurring as five months prior to the incident, it was witnessed by residents and staff members that R2 either hit or attempted to hit R4 in the dining room. In addition, it was also witnessed by staff members that R2 was verbally abusing R1 but the facility did not implement intervention to prevent these incidents from occurring until R1 was hit by R2 in which a 30-day eviction notice was issued.

This report is reviewed and discussed with the administrator and the assistant general manager.

A copy of the report and appeal rights were provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20251230164609

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: 04/01/2026

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

R1 stated that on the day of the incident, R1 was eating in the dining room and suddenly, R2 came behind him/her and hit his/her head. R1 also stated that there were other incidents prior to this event where R1 was verbally abused and pushed by R2. R1 stated that these incidents were reported to one of the facility directors and the administrator.

LPA interviewed R1’s responsible party/friend who stated that when the incident happened, staff took measure immediately and asked R2 to leave the dining room. However, the responsible party said that this incident may have been prevented had R2’s one-to-one caregiver was present at the time.

LPA interviewed R2 who could not remember hitting and yelling at other residents and staff members.

LPA interviewed R3 who stated that R2 was unpredictable and prior to the incident, he/she witnessed R2 hitting another resident (R4) in the dining room and the incident was witnessed by some female servers in the dining room and it was reported to the administrator.

LPA interviewed the facility director (S1) who stated that he was in the dining room when the incident happened but did not witness R1 being hit by R2. However, S1 witnessed R2 calling R1 names that were insulting, abusing and harmful. S1 stated that he immediately asked R2 to use a calm voice but R2 refused to listen so he asked R2 to leave the dining room. S1 reported that R2’s one-to- one caregiver was not present during the incident, and he did not know where the caregiver was.

LPA interviewed 2nd facility director #2 (S2) who stated that prior to the incident, R1 has reported to her that R2 was verbally abusing him/her but R1 did not report being physically abused by R2. S2 stated that this was reported to the administrator. S2 stated that after the incident in the dining room, S2 spoke with R2 and asked R2 to leave the dining room and S2 did not see R2’s one-to-one caregiver.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20251230164609

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: 04/01/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 04/02/2026 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:3) To be free from punishment, humiliation, intimidation, abuse,... This requirement is not met as evidence by	1 2 3 4 5 6 7	The administrator will develop a plan of correction that indicates the facility will take necessary actions/preventive measures to ensure resident's safety. The plan of correction will include staff training.
	8 9 10 11 12 13 14	in December 2025, R1 was hit by R2 and prior to this incident, R2 was verbally abusing R1, other residents and staff members and the facility did not implement prevention measures to prevent the incident from happening which poses an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14	The administrator will provide a copy of the plan of correction to CCL by 4/2/2026.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4