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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601116
Report Date: 04/18/2022
Date Signed: 04/18/2022 10:52:04 AM


Document Has Been Signed on 04/18/2022 10:52 AM - 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: 22DATE:
04/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jen JohnsonTIME COMPLETED:
11:00 AM
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On 4/18/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the outcome of an incident that the facility reported on 3/29/2022 concerning resident #1(R1) AWOL (Absent Without Official Leave). LPA met with the National Care Director, Jen Johnson and explained the purpose of the visit.

During the visit on 3/30/22, LPA interviewed the National Care Director who stated that the concierge at the front desk witnessed R1 leaving the facility and R1's bracelet alarm went off which provided notification to all facility staff that R1 has left the facility unattended. At the same time, staff #1 (S1) was in the lobby and responded to the alarm and followed R1 outside of the facility. Momentarily, staff #2 (S2) also responded to the alarm and went outside looking for R1 and both of them escorted R1 back to the facility safely. R1 did not sustained any injuries due to this incident.

LPA interviewed S1 who stated that he/she responded to R1's alarm, and followed R1 out of the facility until S2 arrived and both of them escorted R1 back to the facility.

The facility reported that R1 is a new resident and R1 just wanted to take a walk.

During the visit on 3/30/22, R1 was not at the facility during LPA's visit, however, the facility reported that upon R1's return, the facility will update R1's care plan to implement safety measures due to this incident.

No deficient cited today.

This report is reviewed and discussed with the National Care Director.

A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
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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