385601116-4-6-2023-14-AS-KHOS-CQYMVR-20230417095709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601116
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:52:26 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
03/06/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230306084323

FACILITY NAME:	COTERIE CATHEDRAL HILL		FACILITY NUMBER:	385601116
ADMINISTRATOR:	LALOYAN,SIRUN SARAH		FACILITY TYPE:	740
ADDRESS:	1001 VAN NESS AVENUE		TELEPHONE:	(415) 915-6615
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	260	CENSUS: 90	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Asst, General Manager and Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not follow Covid-19 reporting protocols.

INVESTIGATION FINDINGS:

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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: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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 8

Control Number 14-AS-20230306084323

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: COTERIE CATHEDRAL HILL	FACILITY NUMBER: 385601116
	VISIT DATE: 04/06/2023

NARRATIVE

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According to SFDPH Nurse, the facility did not report any staff members who tested positive within the outbreak time-frame above.

Based on the facility's internal COVID-19 positive case linelist, there was staff members listed, however based on the linelist that was provided to CCL and SFDPH, there was no staff listed.

After the investigation, this allegation is deemed to be substantiated as the facility failed to notify families, CCL and Local Public Health Department when facility staff tested positive for COVID-19 as directed by Provider Notification Notices (PIN)s including but not limiting to PIN 20-02-ASC, PIN 20-04-ASC, and PIN 20-13-ASC.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this 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.

Report was discussed with the asst. general manager, administrator and building engineer.

A copy is provided and appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 14-AS-20230306084323

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: COTERIE CATHEDRAL HILL	FACILITY NUMBER: 385601116
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/06/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/13/2023 Section Cited CCR 872119(a)(2)	1 2 3 4 5 6 7	87211 Reporting Requirements..a) Each licensee shall furnish to the licensing agency such reports as the Department may require..(2) Occurrences, such as epidemic outbreaks,...	1 2 3 4 5 6 7	The facility will develop a plan to ensure compliance with Title 22- reporting requirement and follow Provider Information Notices (PIN) pertaining to reporting. This plan shall include staff education.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility did not report staff members who tested positive for COVID-19 during an outbreak on December 2022- Feb 2023 which posed potential health and safety risks to resident in care.	8 9 10 11 12 13 14	Facility will provide a copy of the plan and a copy of the staff education sign-in sheet to CCL by 4/13/2023.
	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.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

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
03/06/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230306084323

FACILITY NAME:	COTERIE CATHEDRAL HILL		FACILITY NUMBER:	385601116
ADMINISTRATOR:	LALOYAN,SIRUN SARAH		FACILITY TYPE:	740
ADDRESS:	1001 VAN NESS AVENUE		TELEPHONE:	(415) 915-6615
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	260	CENSUS: 92	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Asst, General Manager and Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not follow Covid-19 masking protocols
Staff did not ensure that resident was eating
Staff did not ensure that resident received their mail in a timely manner.

INVESTIGATION FINDINGS:

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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: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

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 8

Control Number 14-AS-20230306084323

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: COTERIE CATHEDRAL HILL	FACILITY NUMBER: 385601116
	VISIT DATE: 04/06/2023

NARRATIVE

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Regarding to allegation of staff did not ensure that resident was eating, the reporting party stated that resident #1 (R1) tested positive for COVID-19 and staff did not ensure R1 had adequate meal intakes and R1 appeared to have weight loss.

As part of the investigation, LPA interviewed residents, and facility staff who were assigned to care for residents that tested positive for COVID-19.

LPA interviewed 4 facility staff including one who cared for R1 and all of them reported that they assisted resident with their meal services including taking their meal orders, assisting with their meals, checking with them while they were eating, and cleaning up after they were done, placing all the used disposable items into the brown bag and trashing it in the garbage bag.

According to the staff #1 (S1) who was assigned to R1, R1 did not have an appetite couple of meals during R1's isolation period so S1 offered R1 alternate food items and encouraged R1 to consume it and drink liquid to stay hydrated.

LPA interviewed 2 residents who tested positive during the most recent outbreak and both of them reported that staff assisted them with their meals, cleaned their rooms and provided assistance to their personal needs.

After 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: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 14-AS-20230306084323

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: COTERIE CATHEDRAL HILL	FACILITY NUMBER: 385601116
	VISIT DATE: 04/06/2023

NARRATIVE

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Regarding to staff did not ensure that resident received their mail in a timely manner, the reporting party stated that on the facility's website, it advertised that mail would be delivered daily. However, R1 did not get the mail delivered, instead, R1 went to retrieve it and when R1 was not able to do so in December 2022, facility staff did not deliver it to R1 until Jan 2023 which resulted R1 missed Christmas mail greetings from R1's loved ones and other communication from the facility.

As part of the investigation, LPA interviewed facility staff, residents and responsible parties.

According to facility staff, resident's mails are being delivered to them by the concierge unless a resident preferred to get it by themselves.

LPA interviewed 2 residents and both of them reported that their mails are being delivered by facility staff unless they were waiting for an important package and/or a mail then they would go and get it by themselves.

According to responsible party, their loved one's mails are being delivered by facility staff but sometimes their loved one enjoyed going downstairs and retrieved it by themselves.

After the investigation, this allegation is deemed unsubstantiated.

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 reviewed and discussed.

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: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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
03/06/2023 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20230306084323

FACILITY NAME:	COTERIE CATHEDRAL HILL		FACILITY NUMBER:	385601116
ADMINISTRATOR:	LALOYAN,SIRUN SARAH		FACILITY TYPE:	740
ADDRESS:	1001 VAN NESS AVENUE		TELEPHONE:	(415) 915-6615
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	260	CENSUS: 92	DATE:	04/06/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Asst, General Manager and Administrator		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff did not follow Covid-19 testing protocols
Staff did not follow Covid-19 quarantining/isolation protocols

INVESTIGATION FINDINGS:

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On 4/6/ 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-2023030608323. LPA Han met with Assistant General Manager Deborah Suarez and Administrator, Sarah Laloyan and explained the purpose of the visit.

Regarding to allegation of COVID-19 testing protocols, the reporting party stated that the facility's procedure with contact tracing was inaccurate as some residents have cognitive impairment, therefore, they would not remember the duration of exposure with someone who tested positive and the reporting party expressed the facility staff did not wait for the entire 15 minutes after a COVID-19 antigen test was administered to read the result. In addition, the reporting party expressed that the contact tracing would be more accurate if the facility used the resident's tempo/bracelet as it tracked resident's whereabout within the facility.

As part of the investigation, LPA interviewed facility director who stated that facility conducted contact tracing according to the Local Public Health's recommendation and to ensure the accuracy for residents who are cognitively impaired, the facility obtained details from the interdisciplinary team members such as dining room staff, activity staff, etc.

LPA Han interviewed Local Public Health representatives who did not have any concerns with the facility's contact tracing procedures during the outbreak as the facility followed their guidance and eventually conducted rapid response testing.

In regards to staff testing techniques, LPA interviewed facility director and 3 facility staff and all of them were able to articulate the proper techniques performed when they were administering a COVID-19 antigen test.

In addition, LPA interviewed responsible parties and resident and they reported that staff used proper techniques while administering COVID-19 antigen tests.

After the investigation, this allegation is deemed to be unfounded.

Unfounded

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: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 14-AS-20230306084323

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: COTERIE CATHEDRAL HILL	FACILITY NUMBER: 385601116
	VISIT DATE: 04/06/2023

NARRATIVE

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Regarding to allegation of staff did not follow COVID-19 quarantining/isolation protocols, the reporting party stated resident #1 (R1) tested positive for COVID-19 and did not completed the full course of 10-day isolation as R1 was out of isolation on day 8 after testing negative.

As part of the investigation, LPA interviewed facility director, facility staff, responsibility parties and residents.

The facility director denied the allegation and stated that all the residents who tested positive completed their 10-day isolation period even they tested negative prior to the 10-day.

LPA interviewed 4 facility staff who were designated to care for positive COVID-19 residents including a staff who cared for R1 during the outbreak and all of the stated that their residents were on isolation for 10-days.

LPA interviewed 2 residents and 3 responsible parties to residents who tested positive for COVID-19 and all of the reported that they or their loved ones were in isolation for 10-days.

After the investigation, this allegation is deemed to be unfounded.

This agency has investigated these complaints and we have found that the complaints were unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed.

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: 04/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8