Coterie Cathedral Hill

On 08/26/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in response to the allegation received. LPA met with general manager Michael Turner and explained the purpose of today's visit. During the course of the investigation, interviews were conducted, and documentation is reviewed. Due to no further information from the complaining party LPA is unable to determine certain information regarding the allegation such as who signed up the resident with the service as the facility was not involved in that part of that process. Per interview with staff with the general manager of the facility, the facility did not sign up the resident for the services in question, as it was only a referral the facility provided. The facility is not under contract, receive money, or involved in any other business with the outside vendor. Just the referral. Per the facility, they are not allowing the business affiliate to enter the facility any longer, andRead the full finding— CDSS inspection report, August 26, 2025 · control 14-AS-20250819215313

On 5/21/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Matt Turner. LPA toured the facility, interviewed residents, reviewed records, gathered photos and made observations during the course of the investigation. Complaint alleges, staff did not ensure that medications are inaccessible to residents in care. Based upon a review of resident's (R1) medical assessments from 2023 and 2024, it is determined that R1 is not able to manage or store their own medications. In addition, LPA gathered photo evidence showing multiple prescription medications left by staff in R1's bedroom on separate occasions. Allegation, above is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, DivisionRead the full finding— CDSS inspection report, May 21, 2025 · control 14-AS-20250306100512

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 tiRead the full finding— CDSS inspection report, November 21, 2024 · control 14-AS-20240830083504

On 11/14/2024, 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 devices not properly working including elevator and swimming pool lift. Based upon interview with General Manager (S1) LPA found that 1 out of 4 resident utilized elevators located in the lobby were not operating upon time of visit on 9/6/2024. However this does not prevent the overall accessibility for residents to utilize elevators. Upon observation LPA found that 3 elevators were still in functioning condition and accessible for resident use. In addition, LPA was provided documentation of contact with elevator repair services. Allegation also indicates swimming pool lift is inoperable. Based upon observation and interview with S1,Read the full finding— CDSS inspection report, November 14, 2024 · control 14-AS-20240830083504

On 09/05/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the received allegations. LPA met with general manager Matt Turner and LPA explained the purpose of today's visit. During the investigation, LPA conducted interviews and reviewed pertinent documentation related to the complaint allegations. It was discovered that both residents R1 and R2 did sign admission agreements with the facility and had specific move in dates. Due to circumstances, such as a rate increases due to higher level of care being needed for both residents, both residents did not move in, and decided to submit their notices of moving out. Both residents never moved into the facility, but per the admission agreements signed is does indicate a 60 day notice to the facility if a resident decides to move out. The facility is upholding that 60 day notice rule and are charging the residents for those 60 days. Additionally regarding theRead the full finding— CDSS inspection report, September 5, 2024 · control 14-AS-20240709153531

On May 24, 2024 at 9:00 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for a complaint received on December 14, 2023. LPA Calandra was greeted by Matthew Turner, General Manager and explained the purpose of the visit. Assistant General Manager, Deborah Suarez arrived later during the visit. LPA gathered information relevant to the above complaint allegation and conducted interviews. Regarding the allegation that due to a lack in staffing, resident call bells are not responded to in a timely manner, it was found that there were multiple occasions in which resident call buttons were not responded to in a timely manner. Staff have failed to do this based on information gathered. The Department has investigated the complaint allegation of a possible violation of a resident’s personal rights. We have found that the complaint allegation is substantiated. Based on the investigation, the preponderance of evidence standard has been metRead the full finding— CDSS inspection report, May 24, 2024 · control 14-AS-20231214102829

On this day Licensing Program Analysts (LPA) John Calandra, Grace Donato, and Licensing Program Manager(LPM) April Cowan conducted an unannounced complaint investigation visit in order to deliver the findings regarding the allegation received. The LPAs and LPM met with Shirley Cheung, Care Coordination Director(CCD) and Deborah Suarez, Assistant General Manager(AGM) and explained the purpose of today's visit. During LPA Jaime Vado's investigation on October 10, 2023, the LPA conducted interviews, reviewed pertinent documents, and made observations of the memory care unit. LPA Vado could not identify any staff shortages per observations made. The facility scheduling shows staffing is in place and demonstrated they are able to meet the needs of residents. This allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. RepRead the full finding— CDSS inspection report, October 31, 2023 · control 14-AS-20230725122257

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigaiton visit to investigate the allegation received. LPA met with Shirley Cheung who is the resident care director initially then later LPA met with assistant general manager Deborah Suarez and explained the purpose of today's visit. During today's visit LPA discussed the allegation with both staff persons Shirley and Deborah. Infection control plans are discussed and confirmed as being in place. Facility has reported the cases to San Francisco Department of Public Health (DPH) regularly since the first positive discovered on 08/18/2023 up to today. DPH has provided the facility with additional guidance at this time which is provided to LPA. LPA toured the memory care where COVID cases are isolated to in order to observe infection control protocols being in place which they are. UnfoundedRead the full finding— CDSS inspection report, August 23, 2023 · control 14-AS-20230818081109

On July 26, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Executive Director, Sarah Lolayan, and Assistant General Managers, Armando Prado and Deborah Suarez and explained the purpose of the visit. Regarding the allegation, staff do not address scabies outbreak for the residents while in care, according to the reporting party, the residents on the 4th floor, memory care unit are all infested with scabies and the facility is not following protocol by reporting to the state. During the investigation, LPA interviewed Executive Director, two Assistant General Managers, and Care Coordination Director, Shirley Cheung, and reviewed facility records. According to the Executive Director and Care Coordination Director, Resident 1 (R1) was seen by a dermatologist on 7/8/2023 for a rash that did not subside despite treatment that was provided. The Executive Director stated that during this time 4 additional residents were observeRead the full finding— CDSS inspection report, July 26, 2023 · control 14-AS-20230724084145

On 5/10/ 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230328125254. LPA Han met with administrator and explained the purpose of the visit. Regarding to allegation of- facility is without hot water, there is no additional information forthcoming from the complainant, however, the co-complainant stated that a maintenance staff was installing a grab bar in the bathroom in one of the apartments and accidentally punctured a hole in the pipe which resulted the facility of not having hot water for 4 days and residents were not able to take a shower. In addition, the co-complainant stated that the repair would have been fixed a lot sooner had the facility hired an outside plumbing company. As part of the investigation, LPA toured the facility, tested water temperature in multiple rooms on different floors, interviewed Building Engineer and residents. UnsubstantiatedRead the full finding— CDSS inspection report, May 10, 2023 · control 14-AS-20230328125254

On 5/10/2023 , Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230328165214. LPA Han met with administrator and explained the purpose of the visit. Regarding to the allegation of facility doors are not in good repair- the reporting party stated that resident #1 (R1) fell and was injured because the 3rd floor lobby door closed by itself and the same resident was locked outside on the rooftop because the door was not working. In addition, the reporting party stated that often it does not work as the doors start to close on the person who was trying to get in or get out. As part of the investigation LPA conducted facility tour and tested the rooftop and 3rd floor doors, LPA interviewed R1 and building engineer. During the facility tour, LPA observed both the 3rd floor and the rooftop doors were functioning properly. LPA also observed if the door starts to close while someone is still trying to get in or out, the doorRead the full finding— CDSS inspection report, May 10, 2023 · control 14-AS-20230328165214

On 4/6/ 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-2023030608323. LPA Han met with Assistant General Manager, Deborah Suarez, and Administrator, Sarah Laloyan and explained the purpose of the visit. Regarding to allegation of staff did not follow COVID-19 reporting protocols, the reporting party stated that the facility did not report staff members who tested positive for COVID-19 during the outbreak between December 2022 - February 2023. As part of the investigation, LPA interviewed facility staff, facility director, San Francisco Department of Public Health (SFDPH) Nurse and reviewed documents. The facility director acknowledged that there were facility staff who tested positive for COVID-19 during the outbreak and facility did not report it to CCL. SubstantiatedRead the full finding— CDSS inspection report, April 6, 2023 · control 14-AS-20230306084323