<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601116
Report Date: 11/21/2024
Date Signed: 11/21/2024 04:16:21 PM

Unsubstantiated


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
08/30/2024 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20240830083504
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: DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Matt Turner, General ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff not meeting resident needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/21/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by General Manager, Matt Turner. LPA toured the facility, interviewed staff, reviewed facility and resident records and made observations during the course of the investigation.

Complaint alleges facility staff not meeting resident needs in regards to resident (R1) Activities of Daily Living (ADL) including room checks, continence care and medication administration assistance. Based upon interviews with multiple staff (S1, S2, S3, S4) it is indicated that R1's outside provider private caregiver (I1), had dismissed caregiver staff on multiple occasions when staff were attempting to provide ADL services for R1. The facility indicates completed ADL tasks on an electronic tracker (Task Plan). Staff indicated that ADL for R1 is input as "completed by outside service/party". Upon a sample review of May 2024 task tracker records during the time period I1 had provided private caregiver services to R1; LPA observed over 200 input documentation of ADL being "completed by outside services/party" due to staff being dismissed by I1. LPA also conducted a file review of facility Task Plan tracker in which all indicated dates in which staff allegedly failed to meet resident R1 continence and status check ADL were found to be marked as completed.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
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 2
Control Number 14-AS-20240830083504
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: 11/21/2024
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 gathered further information regarding (R1) ADL medication care needs are not met. Complainant reports that staff had administered R1's medication over one hour past scheduled medication administration times. Upon interviews with Care Coordinator Director (S2) and documented statements of General Manager (S1) gathered, it is indicated that the facility staff are allowed to administer medication one hour before or one hour after medication administration times. Upon review of facility medication administration policy LPA confirmed that it is also indicated: staff are "allowed" to assist up to one hour before or after the medication "give time". There however, is no indication in facility policy that staff are required to provide medications at exact times. S1 further indicated that staff are to provide services or attempt to provide services to residents at approximates of schedule times with consideration to staff tending to several other residents in care.

In addition, LPA reviewed medication prescription instruction for R1's prescribed Amoxicillin with claims that medication was not administered within prescription time frame. Upon review of medication prescription, Amoxicillin is only indicated to be taken 3 times per day (AM, PM and Evening) with no specific times that the medication is required to be taken at.

Lastly, LPA conducted a file review of facility Medication Administration Records (MAR) in which all indicated dates in which staff allegedly failed to meet resident R1 medication assistant ADL were found to be marked as completed. Due to a contradicting information gathered an a lack of corroborating evidence, the allegation is found to be unsubstantiated.

A finding that the complaint allegations, facility staff not meeting resident needs is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2