San Francisco RCFE

Allegation investigated: Facility did not provide computer to resident

On October 25, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit to deliver the investigation findings. LPA met with Interim Administrator, Charisse Ann Li and explained the purpose of the visit. Regarding to allegation of - facility did not provide computer to resident. As part of the investigation, LPA interviewed resident - in - question (R1) and interim administrator. According to R1, there is no computer access for residents at the facility which made it impossible for R1 and other residents to search the internet and other activities. The interim administrator acknowledged that there is no electronic device for residents and it is vital for residents to have access to an electronic device. Therefore, the facility will be working on obtaining it for the residents. Based on interviews and observations during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiency is cited on the LIC 9099D under Health and Safety Code. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided. Substantiated LPA interviewed 3 other residents who did their own laundry and all of them stated that they have not had any of their clothes missing from the laundry room. After the investigation, this allegation is deemed to be unsubstantiated as R1 did not report to facility staff when the hats were missing, and R1 was not able to provide additional details of the missing hats. Regarding to allegation of- Staff behavior towards resident was unacceptable, the reporting party reported resident- in - question (R1) experienced unacceptable behavior from staff members. As part of the investigation, LPA interviewed R1 and interim administrator. According to R1, he/she did not like the way he/she was being talked to by staff #1 (S1). R1 denied being mistreated by S1 but did not like the tone of voice such as when R1 did not want to take his/her medication, and felt he/she was being questioned by S1. However, R1 was not able to provide additional details and R1 stated that it was not reported to any team leaders and supervisors. LPA interviewed interim administrator who stated that S1 is being monitored on work related tasks but no one has expressed concerned about S1's tone of voice while talking to residents. LPA interviewed a team leader who reported that residents have not reported any concerns of any staff members being rude to them. LPA interviewed 3 residents and they all reported that facility staff members are caring, doing their best to care for them and they are friendly. After the investigation, this allegation is deemed to be unsubstantiated as R1 stated that he/she was not mistreated by S1 and interim administrator will speak to S1 regarding to the tone of voice while speaking to residents. 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 with interim administrator; a copy is provided.the state’s words, verbatim · CDSS document, Oct 25, 2023 · control 14-AS-20230817121522

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.319(a) · Plan of correction due date: Nov 1, 2023

§1569.319..(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer,.. that can support real-time interactive applications,..and is dedicated for resident use. This requirement is not met as evidenced by facility did not have internal access device such as a computer for residents to access which poses a potential health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 25, 2023

Plan of correction: The administrator/licensee will develop a plan to ensure compliance and will submit a copy of the plan to CCL by 11/1/2023.

Allegation investigated: Facility is retaining residents with higher level of care needs.

On July 21, 2023, Licensing Program Analysts (LPAs) Grace Donato and Komal Charitra conducted an unannounced 10-day complaint visit. LPAs met with Team Leader, Darren Page, and Program Director, Adela Morales joined shortly thereafter. LPAs explained the purpose of the visit. Regarding the allegation that facility is retaining residents with higher level of care, according to the reporting party, the facility is retaining clients who require a higher-level of care and staff are not equipped to provide care for them. According to the reporting party, Resident 1 (R1) has breathing issues and needs oxygen, however facility can’t take anyone with oxygen, Resident 2 (R2) is obsessed with smoking and will wake residents up at night to ask for cigarettes, and Resident 3 (R3) has bad dementia and needs to be in a memory care facility. During the investigation, LPAs reviewed resident files and interviewed the Program Director and Team Leader. Based on interviews conducted with the Program Director and Team Leader, R1 does not Unsubstantiated require oxygen. Based on R1’s physician report dated 7/13/2023, it was documented that R1 has resolved aspiration pneumonia and does not require oxygen. LPAs reviewed R2’s file and the facility house rules regarding smoking. Based on the facility house rules and interviews conducted, the facility does not allow residents to smoke cigarettes inside the facility, however residents are allowed to smoke cigarettes in the designated smoking areas. In addition, based on the interviews conducted, residents are able to smoke when they like as the facility does not have a smoking schedule. Based on R2’s file, LPAs observed a written agreement between the facility and R2 indicating that R2 will receive a fixed amount of cigarettes per day by facility. Furthermore, LPAs reviewed R3’s file. Based on R3’s file, R3 was admitted to the facility on January 2021. Upon admission, R3 did not have a diagnosis of dementia. The physician’s report documentation dated, April 2023 indicated R3 was diagnosed with dementia. According to the Program Director and Team Leader, the facility has been in contact with SFDPH Placement Team and R3’s case manager, however, has not been successful with finding R3 placement. In addition, according to the Program Director, R3 is currently at the San Francisco General Hospital due to R3’s progressive dementia and the social workers and case managers at the hospital are assisting with trying to find R3 placement. Therefore, based on the interviews conducted, files reviewed, and information collected, the allegation that the facility is retaining residents with higher level of care is UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with Program Director, Adela Morales and a copy is provided.the state’s words, verbatim · CDSS document, Jul 21, 2023 · control 14-AS-20230711084418

Allegation investigated: Resident needs a higher level of care Residents are locked out the front door

On 10/21/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannouced visit to deliver the investigtion findings. LPA Han met with the Administrator, Adela Morales and explained the purpose of the visit. LPA was properly screened by the receptionist at the main entrance. Regarding to allegation of- resident needs a higher level of care- LPA Han observed residents in question and all of them are independent with their Activities of Daily Living (ADLs) and ambulation with the exception of one resident who requires some assistance with performing some of the ADLs due to a recent change of condition. According to the Physician's Reports, all of them are able to leave the facility unassisted and they have the capacity for self-care. Furthermore, according to staff, all the residents in question are independent with their ADLs but some of them need a little reminder and encouragement and others need more such as Resident #3 (R3) who needs a lot of convincing and encouragement to perform personal hygiene tasks and overall room cleanliness. Base on observation, record review and interviews during the course of investigation, this allegation is unsubstantiated. Unsubstantiated Regarding to allegation of- residents are locked out the front door, the Reporting Party stated that Resident #1 (R1) and some of other residents are being locked out after leaving the facility from the front door and it is difficult for them to re-enter the facility from the main entrance especially with the residents who require medical device for ambulation as the main entrance is around the block. According to R1, R1 does not use the front door. R1 uses the elevator and the facility's main entrance to exit and to enter the facility. According to Resident #2 (R2), locking the front door is not a problem as R2 uses the main entrance to come back to the facility. According to the Director of the Behavioral Health Service Center, the front door was unlocked up until a few weeks ago as there were too many people congregating by the door and homeless people come in at night so the facility decided to lock the gate as people are leaving to ensure the safety of the residents and staff. In addition, the Director of Behavioral Health Service Center stated that the residents who ambulate with a medical device is being re-directed by the staff who monitors the exit door to take the elevator down to the 1st floor and then exit through the main entrance because it would be unsafe for them to exit from the front door as there are many stairs leading to the door. Base on observation and interviews during the course of investigation, this allegation is unsubstantiated. . Although the above allegations 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 allegations are UNSUBSTANTIATED. During the course of the investigation, LPA Han observed some documents did not reflect the current status of a resident. This deficiency will be cited on LIC809D. This report is reviewed and discussed the Administrator . A copy is provided.the state’s words, verbatim · CDSS document, Oct 21, 2021 · control 14-AS-20210930110757

Type of visit: Case Management - Deficiencies

On 10/21/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced inspection and met with the Administrator, Adela Morales. LPA explained the purpose of the visit and delivered this finding. During the course of the investigation of Complaint Control Number 14-AS-20210930110757, LPA Han observed Resident #1 (R1)'s Appraisal/Needs and Service Plan does not indicate R1's recent accident and hospitalization. The facility acknowledged that R1's Appraisal/Needs and Service Plan was not updated after the recent change of condition. Based on records review, and interviews, the preponderance of evidence has been met. Deficiency was cited today under the California Code of Regulations, Title 22, Division 6. Please see LIC 809-D. Failure to correct the deficiencies may result in civil penalties. This report was discussed with administrator. A copy of this report and licensee’s Appeal Rights forms given to administrator. Appeals must be directed to Licensing Regional Manager.the state’s words, verbatim · CDSS document, Oct 21, 2021

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Nov 4, 2021

RESIDENT RECORDS (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidenced by: Based on records review and interview, the Administrator did not ensure Resident 1's (R1) appraisal and service plan reflect the current health status and needs as it does not reflect R1's recent change of condition which poses an potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Oct 21, 2021

Plan of correction: The Administrator or the designee to update R1's Appraisal/Needs and Service Plan and submit a copy to the Regional Office. The Administrator or the designee will review the regulation, in-service staff and submit a copy of the lesson plan and the sign-in sheet to Licensing by 11/4/2021.

Type of visit: Required - 1 Year

On 9/29/2021, Licensing Program Analyst(LPA) Murial Han and LPA Komal Charitra conducted an unannounced annual inspection. LPAs observed COVID-19 signs posted by the entrance. LPAs were greeted by the Director of Behavioral Health Center, Linda SIms and the Administrator, Adela Morales joined shortly thereafter. LPA Han and LPA Charitra explained the purpose of the visit and LPAs were screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies (facility has designated 2 private rooms, 1 semi-private room, 1 shower room and 2 bathrooms for the quarantine and isolation purposes when needed), PPE supply and the environmental cleaning supply are adequate (the Director of Behavioral Health Center reviews the PPE inventory on a daily basis and replenishes the supplies when needed), bathrooms are equipped with soap and paper towels, however, there are no hand-washing signs posted; some signs are posted through-out the facility such as social distancing in different languages, cough etiquette, etc; trash cans are observed to have foot operated lids. Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. There were signs/stickers on the floor in the elevators and thought-out the facility to remind everyone to maintain social distancing. Residents were observed to be maintaining social distancing during mealtime and in the TV room. LPA Han requested for the following documents to be submitted by 10/4/2021 by noon: - Proof Administrator Certification was submitted, - LIC 500 - LIC 402 - LIC 308 - Review LIC 555 LPAs discussed the following recommendations during the inspection: - Post additional COVID-19 signs in the hallways, the common areas/dinning rooms, the staff lounge, the bathrooms, and the shower rooms. - Post hand-washing signs above each sink. - Remove 2 chairs from the table in the staff lounge and mark off one of the seats on the double seated couch to ensure social distancing is maintained. No deficiency cited today. This report is reviewed and discussed with the Administrator and the Director of Behavioral Center and a copy is provided.the state’s words, verbatim · CDSS document, Sep 29, 2021

Allegation investigated: Staff touched resident in a sexual manner. Staff verbally abused resident.

On 9/9/2021, Licensing Program Analyst (LPA) Murial Han and LPA Komal Charitra conducted an unannounced 10-day initial complaint inspection regarding the above allegations. LPA Han and LPA Charitra met with the Administrator, Adela Morales and explained the purpose of the visit. Regarding to the allegations of staff touched resident in a sexual manner and staff verbally abused resident, these were reported to the Department in the past in reference to Complaint # 14-AS-20210310114055. At that time, the Department has addressed and completed the investigation and determined the allegations to be unfounded. Therefore, after review, this allegation is also unfounded. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. This report is reviewed and discussed with the Administrator. A copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 9, 2021 · control 14-AS-20210831111654

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: Staff engaging in inappropriate interactions in the presence of resident's. Staff made an inappropriate comment towards resident.

On 8/25/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. LPA Filouane met and spoke Administrator Adela Morales, explained the purpose of the visit, and then delivered the findings. Concerning the allegation of staff engaging in inappropriate interactions in the presence of residents, LPA Filouane interviewed the Administrator, the Director of Behavioral Health Center, Linda Sims, and facility staff members. The Administrator stated the resident in question believes that staff member interacts inappropriately when they sit close to each other or when staff are sitting in an alleged wrong manner at their desks. There is no additional evidence to support the inappropriate interactions allegation in the presence of residents. Concerning the allegation of staff making inappropriate comments to a resident, LPA Filouane interviewed the Administrator, the Director of Behavioral Health Center, Linda Sims, and facility staff members. Unfounded Information gathered reveals that one staff member (S1) allegedly told a resident that other staff members informed S1 that the resident is making up stories and reporting things that are not true. S1 denies this allegation. There were no witnesses present to support the allegation. Under Title 22 regulations, there was no inappropriate comment made towards the resident in question. This agency has investigated the complaint. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. A copy of this signed report will be emailed to the Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2021 · control 14-AS-20210603123136

Allegation investigated: Facility staff threatened resident. Facility staff spoke inappropriately to resident. Facility staff retaliated against resident for filing a complaint.

On 8/25/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. LPA Filouane met and spoke Administrator Adela Morales, explained the purpose of the visit, and then delivered the findings. Concerning the allegation of staff threatening the resident in question, LPA Filouane interviewed the Administrator and facility staff members. The Administrator stated staff do not threaten the residents. There was no additional evidence submitted to the Communtiy Care Licensing Division (CLLD). The investigation revealed no witnesses were present during any of the times it was alleged that facility staff spoke inappropiately to the resident in question. After review, this allegation is unfounded. Concerning the allegation of facility staff speaking inappropriately to a resident, LPA Filouane interviewed the Administrator and facility staff. Unfounded There was no additional evidence submitted to CCLD. The investigation revealed no witnesses were present during any of the time(s) it was alleged that facility staff spoke inappropriately to the resident in question. After review, this allegation is unfounded. Concerning the allegation of facility staff retaliating against the resident in question for filing a complaint, LPA Filouane interviewed the Administrator and facility staff. The incident reported to LPA Han and verified with the Administrator revolved around the resident in question and a staff member raising their voices at each other. According to Title 22 regulations, that alone is not a violation. After review, this allegation is unfounded. This agency has investigated the complaint. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. Exit interview conducted with the Administrator. A copy of this signed report will be emailed to the Administrator.the state’s words, verbatim · CDSS document, Aug 25, 2021 · control 14-AS-20210630093333