389210019-10-25-2023-14-AS-KHOS-CXAW28-20231105155356

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 389210019
Report Date: 10/25/2023
Date Signed: 10/25/2023 01:16:12 PM

Unsubstantiated

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
10/20/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231020121237

FACILITY NAME:	SAN FRANCISCO ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	389210019
ADMINISTRATOR:	CALVIN LATIMORE		FACILITY TYPE:	735
ADDRESS:	887 POTRERO AVE.		TELEPHONE:	(628) 206-6375
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94110
CAPACITY:	55	CENSUS: 39	DATE:	10/25/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Calvin Latimore		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff member did not provide assistance to resident as necessary.

INVESTIGATION FINDINGS:

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On October 25, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with administrator and explained the purpose of the visit.

Regarding to allegation of staff member did not provide assistance to resident as necessary, there is no additional information forthcoming from the reporting party. However, during the initial report, the reporting party stated that a resident was distraught, and crying over the phone so the reporting party and another staff attended to resident but the team leader was in an office at the nursing station with the door closed and failed to attend to the resident.

As part of the investigation, LPA interviewed team leader -in - question (S1), facility director and another team leader (S2).

According to facility director, this incident was never reported and stated that there are times that the team leaders stayed in the office at the nursing station with the door closed for privacy when they are talking to physicians, making appointments for residents, etc. However, staff members on the unit should attend to residents and would notify team leaders for incidents that required their attention.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231020121237

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: SAN FRANCISCO ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 389210019
	VISIT DATE: 10/25/2023

NARRATIVE

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In addition, facility director stated that S1 is very dependable and thorough.

LPA interviewed S1 who couldn't remember the incident and stated that he/ she uses the office for privacy when making phone calls as there are residents around the nursing station most of the time. S1 also stated that there are staff members on the unit attending to residents and if resident needs assistance while she is in the office, staff members would notify her immediately.

LPA interviewed S2 who stated that they utilize the office in the nursing station to make phone calls to the physicians, medical offices, etc, and they would close the door for privacy and staff members know to come and get them when needed.

Based on interviews, and observations during the investigation, the above allegation is UNSUBSTANTIATED.

Although the allegations 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 above allegation is unsubstantiated.

This report is reviewed and discussed with the facility program director.

A copy is provided.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC9099 (FAS) - (06/04)

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