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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601116
Report Date: 05/10/2023
Date Signed: 05/10/2023 12:13:04 PM


Document Has Been Signed on 05/10/2023 12:13 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
SF COASTAL AC/SC, 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: 101DATE:
05/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Sarah LaloyanTIME COMPLETED:
12:25 PM
NARRATIVE
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On 5/10/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow up on an incident that was reported by the facility. LPA met with administrator, assistant general manager and resident care coordination and explained the purpose of today's visit.

On 5/8/2023, LPA was notified by the resident care coordination that early that morning at around 12:30am, facility was notified by a hospital that resident # 1 (R1) was found, and appeared lost resulted the hospital visit. R1 was assessed at the hospital and the facility was informed that R1 was ready to return.

According to facility directors, R1 is a resident residing in the memory care unit and during the incident, R1 left the unit from one of the egress exit doors which the alarm should have been triggered as the door opened. However, the alarm did not go off because the alarm was manually turned off by staff.

In addition, facility directors stated that since the incident, facility has provided a one on one sitter for R1, in-serviced staff on resident elopement drill & response checklist, purchased additional device for an exit gate to alarm staff when someone leaves.

During the case management visit, LPA toured the memory care unit, tested the egress doors and observed them to be adequate. When the alarm went off, staff responded it immediately.

Based on interview, facility staff manually turned off the alarm on one the egress doors resulted R1 left the facility unattended.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with facility director. A copy of this report and the Appeal Rights is provided.


SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
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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Document Has Been Signed on 05/10/2023 12:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/11/2023
Section Cited

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87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(2) To be accorded safe,
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The facility has conducted in-services for staff on Resident Elopement Drill and Response Checklist; and purchased an additional device for the exit gate to alarm staff when it opens.
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This requirement is not met as evidenced by staff manually turned off the alarm on one of the egress doors in the memory care unit resulted R1 leaving the facility unattended which posed an immediate health risk for resident in care.
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Plan of Correction completed and submitted on 5/10/2023.

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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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2023
LIC809 (FAS) - (06/04)
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