Sagebrook Senior Living at San Francisco

Allegation investigated: Staff did not repair resident's window.

On August 15, 2023, Licensing Program Analysts (LPA) Murial Han and LPA John Calandra conducted an unannounced 10-day complaint inspection. LPAs met with Sales Director, David Estrada and explained the purpose of today's visit. The administrator and maintenance director arrived shortly thereafter and assisted with the rest of the inspection. During today's visit, LPAs toured resident-in-question (R1)'s room, tested the bathroom window, interviewed administrator and maintenance director. Regarding to allegation of - staff did not repair resident's window, during the initial reporting, the reporting party stated that R1's bathroom window is very hard to open and close and the reporting party is worried that R1 would get hurt while doing that. Substantiated During the tour of R1's room, LPAs attempted to open and close the bathroom window but it was very tight. R1 attempted to open and close the window, however, R1 was not able to do so due to the tightness of the window. The sales and marketing director was able to open and close the bathroom window but acknowledged that it took a lot of strength. The administrator and the maintenance director were not aware of the bathroom window problem in R1's room, however, after attempting to open and close it, they acknowledged that it was tight, it took a lot of strength to operate it and it would be hard for R1 to open and close it. The maintenance director spray WD-40 oil around the window frame to loosen it but it was not successful. After the investigation, this allegation is deemed to be substantiated. Based on interviews, observations 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 Administrator, and Appeal Rights provided.the state’s words, verbatim · CDSS document, Aug 15, 2023 · control 14-AS-20230808165248

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Aug 18, 2023

87303 Maintenance and Operation...(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by R1's bathroom window is very hard to open and close which poses a potential health risk to resident in care.the state’s words, verbatim · CDSS document, Aug 15, 2023

Plan of correction: The administrator will provide a repair completion date to CCL by 8/18/2023. Upon completion of the repair, the administrator will provide proof to CCL.

Allegation investigated: Facility did not repair resident's window. Facility radiator heater is leaking. Facility placed a hazardous item next to resident's bed.

On 5/31/2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20230427140227. LPA Han met with administrator and explained the purpose of the visit. Regarding to allegation of - facility did not repair resident's window, the reporting party stated that resident #1 (R1) has been residing at the facility for 2 years and the window in the room has never operated correctly. The responsible party and the reporting party has made many requests verbally and in writing to fix the window but it is still inoperable. As part of the investigation, LPA toured R1's room, interviewed maintenance director, administrator and reviewed written communication correspondences. Substantiated According to the maintenance director, he/she was made aware of the broken window since December 2022. In addition, the maintenance director stated that a window company came to the facility a few months ago to assess the window and determined that it needed to be replaced and provided a quote for the replacement. Furthermore, the maintenance director stated that the quote was submitted to the corporate office for approval. The administrator acknowledged that R1's window has been broken for a long time and the facility is in process of getting it replaced. The administrator stated that the responsible party was offered to have R1 move into another room while waiting for the replacement. Based on the documentation provided by the facility, on January 1, 2022, the responsible party informed the administrator in writing that R1's window has been broken for 10 months, this safety concern has been reported to facility staff but it was not addressed. A year later on Jan 18, 2023, the window was still not fixed and/or replaced. The responsible party requested the facility to fix it immediately or move R1 to another room and subsequently, R1 was offered to move to another available room. During the initial complaint visit on 5/3/2023, LPA observed R1's window was not fixed and there were towels by the window seal to keep it open. After the investigation, this allegation is deemed to be substantiated as R1's window has been broken since 2021 and it was reported to facility staff and directors. R1 was offered another room, however, it was done a year later requested by the responsible party. Regarding to allegation of- facility radiator heater is leaking, the reporting party stated that the facility was made aware by the reporting party and the responsible party that the radiator in R1's room has been leaking but nothing was done. As part of the investigation, LPA interviewed maintenance director and reviewed written communication correspondences. During the initial complaint visit on 5/3/2023, LPA observed paper towels placed underneath the heater radiator due to leaks. The maintenance director acknowledged that the radiator has been leaking and the paper towel is placed to keep that area dry. After the investigation, this allegation is substantiated. Regarding to allegation of- facility placed a hazardous item next to resident's bed, the reporting party stated that facility provided a space heater in place of radiator for heat and it is placed next to R1's bed which could be a safety hazard. As part of the investigation, LPA reviewed the Comfort Zone Compact Heater manufacture instruction for the space heater and interviewed the maintenance director. According to the Comfort Zone Compact Heater instructions, one of the warning: fire hazard is do not use near combustible materials; keep combustible materials such as furniture, pillows bedding, papers, clothes and curtain at least 3 feet (0.9) from the front of the heater. However, during the initial complaint visit on 5/3/2023, LPA observed the Comfort Zone space heater was placed on top of a night stand that was next to R1's bed with a small gap in between the night stand and the bed. In addition, the maintenance director stated the space heater was placed in R1's room to provide heat as the radiator was broken and the maintenance director acknowledged that it was placed too close to R1's which could be a safety hazard. After the investigation, this allegation is deemed to be substantiated. Based on interviews, observations 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 Administrator, and Appeal Rights provided.the state’s words, verbatim · CDSS document, May 31, 2023 · control 14-AS-20230427140227

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87307(d)(3) · Plan of correction due date: Jun 1, 2023

87307 Personal Accommodations and Services..(d) The following space and safety provisions shall apply to all facilities:..(3) All persons shall be protected against hazards within the facility... The requirement is not met as evidence by facility provided a space heater for R1 to replace the heater as the heater was malfunctioned and the space heater was observed next to resident's bed which posed an immediate health risk to resident in care.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The administrator/licensee will conduct rounds to ensure facility is using devices following the manufacture instructions. In addition, the administrator/licensee will develop a plan to prevent this from happening again and the plan shall include staff training. The administrator will submit the findings from the rounds and will submit a copy of the plan to CCL by 6/1/2023.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jun 8, 2023

87303 Maintenance and Operation...(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by R1's window has been broken since 2021 and the heater radiator has been broken for many months which posed a potential risk for resident in care.the state’s words, verbatim · CDSS document, May 31, 2023

Plan of correction: The administrator/licensee will develop a plan to ensure facility is in good repair at all times and when repair is needed, the work shall be completed in a timely manner or other alternative shall be offered in a timely manner. The administrator will provide an estimated date of repair completion or an alternate plan to address the broken window by 6/8/2023. The administrator will submit a copy of the plan to CCL by 6/8/2023

Allegation investigated: Food service is inadequate Facility staff failed to meet residents' needs Facility staff mismanaged resident's medication

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegations. LPA met with health and wellness director Jennine Chan and explained the purpose of today's visit. During the investigation LPA conducted multiple interviews, reviewed pertient complaint documents, and obtained photos. The above allegations could not be proved or disporved by LPA during the investigation process. LPA could not meet the perponderance of evidence standard to prove that they did take place. These allegations are unsubstantiated. Report is reviewed with Jennine Chan. No citations issued. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 24, 2023 · control 14-AS-20200803161119

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 illegally evicted resident

On 5/3/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20230309165530. LPA Han met with sales director and LPA explained the purpose of the visit. Regarding to allegation of- staff illegally evicted resident, the reporting party stated that he/she did not report it. However, CCL received this complaint, and LPA conducted an investigation. As part of the investigation, LPA interviewed facility administrator, and R1's case manager. LPA interviewed the administrator who denied the eviction and stated that R1 was admitted from a hospital with a plan to stay at the facility for 30 days then return home. After the 30 days, the facility was directed by R1's case manager that R1 wanted to return home as planned and the facility worked with R1's case manager to get R1 home. Unfounded In addition, the administrator stated that on the day of the discharge, facility provided a caregiver to escort R1 home where R1's friend was present. LPA spoke to R1's case manager who validated that the facility was instructed to discharge R1 home per R1's directive. After the investigation, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis. This report is reviewed and discussed with the sales director A copy is provided.the state’s words, verbatim · CDSS document, May 3, 2023 · control 14-AS-20230309165530

Type of visit: Case Management - Incident

On 5/3/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility. On 5/1/2023, facility reported resident #1 (R1) was admitted to a skilled nursing facility on 1/20/2023 and returned on 4/26/2023 at 5PM. On 4/27/2023 at 1:30AM, a caregiver provided care to R1 and at 2:30AM, the same caregiver witnessed R1 to be unresponsive. Caregiver notified a med tech who observed R1 to be pale with no pulse then proceeded with calling 911. At 3:10AM, R1 was pronounced by 911. At 10AM, R1 was picked up by Coroner and taken to the mortuary. During today's visit, LPA requested for documents; LIC 602, reappraisal, service plan, hospital records and facility documentation to be submitted to CCL by 5/4/2023. No deficiency cited today. This report is discussed and reviewed with sales director.the state’s words, verbatim · CDSS document, May 3, 2023

Allegation investigated: Facility failed to provide adequate food service

On 3/15/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20221230101902. LPA Han met with the Sales Director and the resident service director. LPA explained the purpose of the visit. Regarding allegation of - facility failed to provide adequate food service, the reporting party stated that, resident -in- question (R1) reported that the facility served bad hamburger and uncooked hot dogs, the facility did not provide the foods that R1 had requested for and instead, provided the foods that R1 did not order and R1 was told by staff that there was no snacks available. LPA interviewed the administrator who denied the allegation and stated that R1 did not like hamburger as R1 did not eat it until 4 hours later and the hot dog was fully cooked but the way it was cooked left the center a little pinkish. The administrator also stated that there is always snacks such as chips, cookies and fruits in the dining room bistro and staff checks it everyday to replenish it when needed. Unsubstantiated Concerning to R1 did not get the food items as ordered, the administrator stated that upon R1's admission, R1 selected the items from the weekly menu for breakfast, lunch, and dinner and when R1 did not get items as ordered, staff went to the kitchen and got it. The administrator also stated that since the mistakes were reported, the management team such as the resident care director, the dining service director and the administrator have met with R1 several times to improve R1's dining experience. In addition, the administrator has implemented a new system to improve tray/meal accuracy. According to the dining service director, he/she has met with R1 multiple times concerning food preferences and accuracy. He/she has reminded kitchen staff to check food accuracy before it leaves the kitchen and in-serviced them on improving communication. The dining service director also stated that since the new system that was implemented by the administrator, tray/meal accuracy has improved for R1. In addition, the facility staff brought R1 additional snacks that R1 did not order to ensure R1 has enough of it but R1 mistaken it as staff did not follow his/her food preferences. LPA interviewed facility staff who stated that when R1 did not get the food items as ordered, they would go to the kitchen and get it for R1 but that only happened when R1 was first admitted to the facility. LPA interviewed 4 residents and all of them reported that the facility serves good food, the dining experience is great and there are snacks available. Based on observation, interviews and record reviews during the course of the investigation this allegation is deemed to be unsubstantiated. However during the investigation visit, LPA reviewed R1's selective menu and under beverages, R1 selected orange juice but R1 was served apple juice. This observation will be documented on an advisory notes (LIC 9102 Technical Assistance). Although the above allegation 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.the state’s words, verbatim · CDSS document, Mar 15, 2023 · control 14-AS-20221230101902

Type of visit: Required - 1 Year

On 1/5/23, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Resident Care Director, Jennine Chan. LPA explained the purpose of the visit and LPA was 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, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels; COVID-19 signs are observed to be posted through-out the facility; residents have their own rooms except for couples; hand washing instruction is posted by the hand washing stations; hand sanitizers are observed at varies locations within the facility. Residents and staff are being screened for COVID-19 on a daily basis and visitors when they entered the facility. During the tour, LPA observed both medication rooms were open with staff members present and staff reported that the rooms are locked at all times when no one is there. First aide kits are observed to be equipped and stored in the medication rooms. A comfortable temperature is maintained, lighting is sufficient for comfort. The facility appeared to be cleaned and tidy; dinning rooms are observed to be spacious, comfortable and furniture is spaced out. During today's visit, LPA Han requested for the following documents to be submitted to CCL by 1/10/23: -LIC308 Designation of Administrative Responsibility -LIC500 Personnel Report -Administrator Certificate No deficiency cited today. This report is reviewed and discussed with the Resident Care Director, Jennine Chan. A copy is provided.the state’s words, verbatim · CDSS document, Jan 5, 2023

Type of visit: Case Management - Incident

On 7/19/2022 Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up visit to deliver the outcome from the case management visit on 6/20/22 concerning an incident that was reported by the facility on June 3, 2022. On June 3, 2022, CCL received a LIC624 (Unusual Incident/Injury Report) from the facility regarding resident #1 (R1) was delivering mail to resident #2 (R2) and was told by R2 not to touch the mail that does not belong to R1. R1 appeared upset, left the facility and went to a nearby store where R1 was witnessed by a bystander performing an unusual activity which triggered the bystander to call 911. In addition, the bystander also called the facility to confirm R1 was a resident at the facility. Based on the documents provided by the facility, R1 is able to leave the facility unassisted, and according to staff, R1 enjoys to walk outside of the facility and returns when R1 is ready. Concerning to resident's mail, staff stated that facility has a system to ensure mails are delivered to the residents on the day as they arrive. However, the mails were delivered late on the day prior to the incident and they were left on the receptionist desk. On the next morning, R1 got hold of them, took the mails that belonged to R2 and delivered them to R2 as a nice gesture but it was not appreciated by R2 which made R1 upset and left the facility. The staff also reported that there was no alteration between R1 and R2. Based on record review and interviews, no deficient cited. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jul 19, 2022

Type of visit: Case Management - Incident

On June 20, 2022, Licensing Program Analyst (LPA) Murial Han conducted an case management visit regarding an incident that was reported to CCL. LPA met administrator and explained the purpose of the visit. On June 3, 2022, CCL received a LIC624 (Unusual Incident/Injury Report) from the facility regarding resident #1 was delivering mail to resident #2 and was told by resident #2 not to touch the mail that does not belong to resident #1. Resident #1 appeared upset, left the facility and went to a nearby store where resident #1 was witnessed by a bystander performing an unusual activity which triggered the bystander to call 911. In addition, the bystander also called the facility to confirm resident #1 was a resident at the facility. After the facility was notified by the bystander of a potential resident, facility staff went to the nearby store and confirmed that it was resident #1. Resident #1 returned to the facility later on that same day after the hospital stay. During today's visit, LPA interviewed the administrator and collected some documents and addition documents- Care Plans, and medical records will be provided by 6/21/22. This incident requires further follow-up. This report is reviewed and discussed with the administrator. A copy is provided.the state’s words, verbatim · CDSS document, Jun 20, 2022

Allegation investigated: Staff were not responsive to resident's calls for assistance. Facility is not in good repair.

On 11/3/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings. LPA Han met with the Administrator and explained the purpose of the visit. Regarding to allegation of- staff were not responsive to resident's calls for assistance. LPA Han interviewed the Clinical Director who denied the allegation. LPA Han interviewed residents regarding the call for assistance response time and they reported that the staff is very helpful, very nice and very attentive. After investigation, this allegation is deemed to be unsubstantiated. Regarding to allegation- facility is not in good repair, the Maintenance Director reported that there was a leak in one of the rooms a few months ago that caused by an accident and it was fixed within a couple of hours. LPA Han toured the facility and residents' rooms and observed all of them were cleaned, no cracks, no leaks, and no signs of any damages. LPA Han interviewed residents who have been residing at the facility from the range of 9 months to 5 years and all of them reported that the facility is in good shape. After the investigation, this allegation is deemed unsubstantiated. This report is reviewed and discussed with the Administrator. A copy is provided. Unsubstantiated Regarding to allegation of- staff did not respect resident's privacy, the Reporting Party is alleging that while staff #1(S1) was showering Resident #1 (R1), two other staff barged into the bathroom room despite R1 asked them not to. LPA interviewed S1 who denied the allegation and stated that the two staff asked for R1's permission and R1 agreed to it. In addition, S1 stated that he/she used a towel to cover R2 before the two staff entered the bathroom. There was no additional information forthcoming from the Reporting Party. After investigation, this allegation is deemed 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. This report is reviewed and discussed with the Administrator. A copy is provided.the state’s words, verbatim · CDSS document, Nov 3, 2021 · control 14-AS-20210914092034

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87217(b( · Plan of correction due date: Nov 24, 2021

SAFEGUARDS FOR RESIDENT CASH, PERSONAL PROPERTY AND...(b) Every facility shall take appropriate measures to safeguard residents'..personal property and valuables which have been entrusted to the licensee or facility staff..... This requirement is not met as evidenced by the facility proceeded to put a dry clean duvet in a regular washer which posed potential health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: If the facility has not reimbursed the resident the facility shall do so by the due date 11/24/2021 The Administrator will in-service housekeeping staff on proper ways to safeguard residents' personal belongs. The Administrator will provide a copy of the lesson plan and a copy of the sign-in sheet by the plan of correction due date 11/24/2021.

Type of visit: Case Management - Deficiencies

On 7/27/2021, the facility reported that a caregiver had been removed from the facility after it was found to have engaged in an inappropriate contact with a resident. The Department made a case management visit regarding the incident on 7/28/2021 and initiated an investigation. On 11/3/2021, Licensing Program Analyst (LPA) Murial Han conducted a follow-up to deliver the findings of the investigation. The Department determined that on 7/26/2021, a staff member (S1) indicated to another staff (S2) intentions to give a resident (R1) a shower. After a few minutes, S2 went to assists S1 and found S1 with pants down and in underwear within the bathroom and in the presence of R1. S1 denied a sexual encounter but acknowledged an emotional relationship with R1; therefore, the S1 was removed from the facility immediately. During the investigation, the Department collected documentation and conducted interviews. S1 denies engaging in sexual contact with R1 but acknowledges a relationship with the resident. R1 is unable to communicate and unable to acknowledge any relationship, and given R1’s health condition, unable to consent. No other staff acknowledged awareness of S1’s claimed relationship with R1. Based on interviews conducted, there is preponderance evidence to show that S1 engaged in inimical behavior and engaged in inappropriate contact with a resident in care. Therefore, facility staff violated the resident’s personal rights. Appeal rights and penalty assessments have been explained to Facility Representative, and the following Type A deficiency is cited based on Title 22, Division 6 of California Code of Regulations.the state’s words, verbatim · CDSS document, Nov 3, 2021

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.58(a)(2) · Plan of correction due date: Nov 3, 2021

§1569.58 Persons prohibited from being a licensee,..(a) The department may prohibit any person from being a licensee,...or continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee, prospective employee, or person who is not a client and who has done any of the following:(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.the state’s words, verbatim · CDSS document, Nov 3, 2021

Plan of correction: Facility is to remove S1 Immediately from having any contact with residents. S1 was removed on 7/26/2021 and has been terminated. Deficiency cleared.

Type of visit: Case Management - Incident

On 11/3/21 Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up visit to deliver the investigation outcome concerning an incident that was reported to the Department on 9/20/2021 concerning Staff 1 (S1) alleged Staff #2 (S2) strongly pulled Resident #1 (R1)'s ponytail in the dinning room when asking R1 to sit down on the couch. During the initial visit on 9/22/2021, LPA Han requested for documents, interviewed staff. reviewed records and observed R1 who appeared to be calmed and was lying down on the couch watching TV with other residents. R1 was not able to recall the incident. LPA Han interviewed S2 who denied of pulling R1's ponytail and stated that he/she tapped R1's shoulder as R1 was leaving the dining to redirect R1 back into the dinning room to watch TV where S2 can continue to provide supervision. LPA Han interviewed the Clinical Director and the Administrator regarding to the facility's investigation process. The facility followed their investigation protocols and determined that the allegation to be unsubstantiated, however as an abuse prevention, the facility has provided an in-service to staff on "Elder Abuse Reporting". After the investigation, no deficient cited.the state’s words, verbatim · CDSS document, Nov 3, 2021

Type of visit: Case Management - Incident

On 9/22/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident reports/ SOC 341 that was reported by the facility. LPA Han met with the Clinical Director, Jennine Chan and explained the purpose of the visit. The facility reported that Staff 1 (S1) alleged Staff 2 (S2) strongly pulled Resident 1 (R1)'s ponytail in the dining room when asking her to sitting down on the couch. The Clinical Director conducted a skin assessment for R1 and no injuries were noted. During today's visit, LPA interviewed staff, observed R1 and requested for documents. This incident requires further investigation. This report is discussed and reviewed with the Clinical Director. A copy is provided.the state’s words, verbatim · CDSS document, Sep 22, 2021

Type of visit: Case Management - Other

On 9/142021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings from a Case Management visit on 8/23/2021. LPA Han met with the Executive Director, Fili Howard and explained the purpose of the visit. The incident happened on 8/17/2021 around breakfast time, when the Medication Technician was preparing medication in the dining room, he/she heard a loud noise and witnessed that R1's right arm was extended upward in a swinging motion and R2 was on the floor. The staff reported that R2 has a tendency of grabbing other resident's foods so when R1 saw R2 attempted to grab R3's food, R1 probably pushed R2. During LPA's visit on 8/23/2021, LPA observed R1 and R3 to be calmed in the dining room and awaiting for their lunch. R1 was sitting at a table and having conversation with another resident. LPA observed several staff members in the room assisting the residents. LPA interviewed R2 and R3 regarding the incident and both of them couldn't remember anything about it. LPA interviewed three caregivers who were in the dining during the incident and they stated did not witness the incident as they were assisting other residents with their meals but they looked up as they heard a loud noise and witnessed R2 on the floor. They reported that R2 has a tendency of grabbing other resident's food and they were trained on how to distract R2 from doing that. After the incident, the facility has updated R1's care plan including medication review to address the recent aggressive behavior. R2 was transferred to the acute hospital for the fall and the facility requested the hospital to perform a medication review prior to discharge due to the recent behaviors. R2 has returned to the facility and the staff members reported that R2 seemed to be calm and comfortable. There is no further incidents. No deficiency is cited today. This report is reviewed, discussed with the Administrator, Fili Howard, a copy is provided.the state’s words, verbatim · CDSS document, Sep 14, 2021

Type of visit: Case Management - Incident

On 8/23/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident reports/ SOC 341 that was reported by the facility. LPA Han met with the Executive Director, Fili Howard and explained the purpose of the visit. The incident happened 8/17/2021 around breakfast time, when the Medication Technician who was preparing medication in the dining room, he/she heard a loud and witnessed that R1's right arm was extended upward in a swinging motion and R2 was on the floor. The staff reported that R2 has a tendency of grabbing other resident's foods and R1 was trying to stop R2 from grabbing R3's food. During the visit, LPA interviewed the Executive Director, the staff members who were in the dining room during the incident, and the residents who were involved in the incident. In addition, LPA observed the dining room area and requested for additional documentation for the residents who were involved. This incident requires further investigation. This report was reviewed and discussed with the Executive Director and a copy is provided.the state’s words, verbatim · CDSS document, Aug 23, 2021

Type of visit: Case Management - Incident

On 07/28/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted a Case Management visit at the facility with Executive Director (ED) Angela Boucher Tunin, regarding an Incident Report received by the Community Care Licensing Division on 7/27/21. The incident involves a female resident (R1) and a male caregiver (C1). LPA Filouane reviewed the information reported on the Incident Report. The facility's investigation is currently ongoing. In an interview with the ED, LPA Filouane clarified the information reported on the Incident Report. The incident occurred on 07/26/21, when another caregiver (C2) had entered the Memory Care unit of the facility. It is reported in the Incident Report and in an interview with the ED that C2 opened the restroom door and witnessed C1 with their back turned, hands raised, and their trousers down to their knees with their underpants still raised, standing close towards R1. R1 was leaning against the restroom sink with their hands on their side. R1 wore only a bathrobe. It is reported that after C2 witnessed that C1 was undressed with a resident, C2 had went to inform a Medical Technician on duty. The Medical Technician then arrived at the restroom in the Memory Care unit and witnessed the resident unclothed and C1 showering the resident. The Medical Technician reported the incident to the Executive Director, who instructed C1 to leave the facility pending investigation. The Executive Director states that on the same day of 07/26/21, after the ED had instructed C1 to leave the facility, C1 was found in a resident's closed room with R1 and another resident. The Executive Director made their way to the room and estimates that C1 was in the room with R1 and another resident for less ten minutes. According to the ED, the ED asked what C1 was doing in the room, and C1 stated they were telling R1 that they were leaving. San Francisco Police Department arrived at the facility on 07/26/21 and interviewed the resident. Facility management interviewed the caregiver and Medical Technician. LPA requested physician reports of two residents, documentation of facility interviews with staff members, and will contact SFPD for the police report and R1's hospital visit results. Exit interview conducted with Executive Director. This report will be emailed to the Executive Director.the state’s words, verbatim · CDSS document, Jul 28, 2021