Coterie Cathedral Hill

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

On 9/24/2026, Licensing Program Analyst (LPA) Grace Donato conducted an announced case management visit to follow up on an incident that was reported by the facility. LPA met with Executive Director, Matthew Turner and explained the purpose of today's visit. LPA received an incident report last 9/17/2026 stating that on 09/16/2026 at approximately 8:22 am, resident (R1) was waiting by the memory care exit door while paramedics were preparing to leave the unit. Memory Care staff asked R1 where he/she was going. R1 stated he/she was a visitor and was leaving thecommunity. R1 was allowed to exit memory care and followed behind the paramedics into the lobby. R1 later told Concierge he/she was looking for his/her car and was allowed to exit the community. On R1's medical assessment, R1 has history of elopement behaviors and that R1 needs to live in a secured memory care environment. Based on the records reviewed, R1 was able to leave the facility unassisted. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and a copy of report and appeals rights are provided.the state’s words, verbatim · CDSS document, Sep 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Sep 24, 2026

87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement is not met as evidenced by Based on interviews, R1 left the facility unassisted which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: Facility has already corrected the citation by retraining all staff members about Elopement.

Type of visit: Case Management - Incident

On 9/24/2026, Licensing Program Analyst (LPA) Grace Donato conducted an announced case management visit to follow up on an incident that was reported by the facility. LPA met with Executive Director, Matthew Turner and explained the purpose of today's visit. LPA received an incident report regarding a staff (S1) hitting a resident (R1) on 8/10/2026. Incident happened on 8/7/2026. On 8/7/2026 at approximately 4:30am, R1 exited the apartment following a staff wellness check and walked through the memory care hallway. Another care staff member redirected R1 to R1s apartment. R1 later exited the apartment wearing a sweater and continued walking through the neighborhood. R1 subsequently approached S1 who had completed the wellness check. Facility video shows R1 attempting to strike the S1 and then striking the S1s head with an open hand. S1 grasped both of the R1s hands. During the interaction, S1 struck the R1s head once and the shoulder with an open hand. R1 and S1 continued holding each other's hands until the nurse arrived, separated them, and redirected R1. Based on the records reviewed, S1 struck R1s head twice during an altercation violating the residents personal rights. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed and a copy of the report and Appeal Rights is provided.the state’s words, verbatim · CDSS document, Sep 24, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87568.1(a)(3) · Plan of correction due date: Sep 24, 2026

87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This was not met as evidenced by: Based on interviews and records review, S1 hit R1 twice in the head during an altercation which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 24, 2026

Plan of correction: Facility has already conducted in-service training about how to handle agitated/aggressive residents & residence abuse and reporting process.

Allegation investigated: Staff did not prevent a resident from hitting another resident in care.

On April 1, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the complaint findings. LPA met with administrator and the assistant general manager, Deborah Suarez and LPA explained the purpose of today's visit. Regarding the allegation of, staff did not prevent a resident from hitting another resident in care- the reporting party stated that resident in question (R1) was hit in the head by resident #2 (R2) in the dining room. R1 stated that this incident was witnessed by the manager and the manager asked R2 to leave the dining room. As part of the investigation, LPA interviewed R1, R1’s responsible party, R2, resident #3 (R3), administrator, and facility directors. Substantiated LPA interviewed the administrator who stated that prior to the dining room incident, there were reports that R2 was calling R1 names but there were no incidents of physical abuse. The administrator acknowledged that there was an incident that happened in the dining room where R2 was yelling at R4 but it was not reported that R4 was hit and due to R4’s diagnosis, it was unclear whether he/she was hit. In addition, the administrator stated that initially R4's responsible party reported that R4 was not hit but subsequently reported being hit. The administrator stated that after R2 hit R1, the facility issued a 30-day discharge notice to R2 and R2’s responsible party to ensure the safety of R2 and the other residents at the facility. Regarding the one-to-one caregiver who was not present during the incident, the administrator stated that this person was hired by R2’s responsible party to ensure R2 did not leave the facility unsupervised due to R2's diagnosis. The administrator stated that on the day of the incident, the private caregiver was sitting in a room monitoring the elevators and did not have a line of sight to the dining room when the incident occurred. After the investigation, this allegation is substantiated. Based on interviews and record reviews, the facility did not prevent this incident from occurring as five months prior to the incident, it was witnessed by residents and staff members that R2 either hit or attempted to hit R4 in the dining room. In addition, it was also witnessed by staff members that R2 was verbally abusing R1 but the facility did not implement intervention to prevent these incidents from occurring until R1 was hit by R2 in which a 30-day eviction notice was issued. This report is reviewed and discussed with the administrator and the assistant general manager. A copy of the report and appeal rights were provided. R1 stated that on the day of the incident, R1 was eating in the dining room and suddenly, R2 came behind him/her and hit his/her head. R1 also stated that there were other incidents prior to this event where R1 was verbally abused and pushed by R2. R1 stated that these incidents were reported to one of the facility directors and the administrator. LPA interviewed R1’s responsible party/friend who stated that when the incident happened, staff took measure immediately and asked R2 to leave the dining room. However, the responsible party said that this incident may have been prevented had R2’s one-to-one caregiver was present at the time. LPA interviewed R2 who could not remember hitting and yelling at other residents and staff members. LPA interviewed R3 who stated that R2 was unpredictable and prior to the incident, he/she witnessed R2 hitting another resident (R4) in the dining room and the incident was witnessed by some female servers in the dining room and it was reported to the administrator. LPA interviewed the facility director (S1) who stated that he was in the dining room when the incident happened but did not witness R1 being hit by R2. However, S1 witnessed R2 calling R1 names that were insulting, abusing and harmful. S1 stated that he immediately asked R2 to use a calm voice but R2 refused to listen so he asked R2 to leave the dining room. S1 reported that R2’s one-to- one caregiver was not present during the incident, and he did not know where the caregiver was. LPA interviewed 2nd facility director #2 (S2) who stated that prior to the incident, R1 has reported to her that R2 was verbally abusing him/her but R1 did not report being physically abused by R2. S2 stated that this was reported to the administrator. S2 stated that after the incident in the dining room, S2 spoke with R2 and asked R2 to leave the dining room and S2 did not see R2’s one-to-one caregiver.the state’s words, verbatim · CDSS document, Apr 1, 2026 · control 14-AS-20251230164609

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 2, 2026

87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:3) To be free from punishment, humiliation, intimidation, abuse,... This requirement is not met as evidence by in December 2025, R1 was hit by R2 and prior to this incident, R2 was verbally abusing R1, other residents and staff members and the facility did not implement prevention measures to prevent the incident from happening which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Apr 1, 2026

Plan of correction: The administrator will develop a plan of correction that indicates the facility will take necessary actions/preventive measures to ensure resident's safety. The plan of correction will include staff training. The administrator will provide a copy of the plan of correction to CCL by 4/2/2026.

Type of visit: Required - 1 Year

On 12/8/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Matthew Turner, General Manager and explained the purpose of the visit. LPA reviewed 10 resident files. All were observed to be complete except for one resident, R1 that was missing Ambulatory or Non-Ambulatory status listed in their Medical Assessment. During file review, LPA observed that one resident, R1 was missing Ambulatory or Non-Ambulatory status listed in their Medical Assessment. A Technical Violation was provided for this. LPA reviewed 8 staff files. All were observed to be complete. A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. LPA collected 3 Administrator's certificates. No deficiencies cited during today's visit. The Annual inspection will be completed at a later date. An exit interview was conducted. This report was reviewed with facility representative and a copy provided via email.the state’s words, verbatim · CDSS document, Dec 8, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff mismanaged resident's medications. Staff did not respond to resident's call button in a timely manner. Staff did not provide services to resident as stated in care plan. Staff did not notify resident's responsible party of changes of resident's care plan. Staff overcharged resident.

On 12/1/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint. LPA was greeted by Matthew Turner and explained the purpose of the visit. Complaint alleged that staff mismanaged resident’s medication. According to the Reporting Party, there would be times where medications would be found on the floor of R1’s room or it was evident that R1 was not getting their medications. Based on document review and interviews, facility staff did handle R1’s medications for them. LPA toured the physical plant as part of the investigation. Based on observations and interviews, no evidence of mismanagement of medications could be found as R1 is no longer a resident of the facility and their records are no longer stored at the facility. Unsubstantiated Complaint also alleged that staff did not respond to resident’s call button in a timely manner. Reporting Party alleged that when R1 pushed their call button, no staff would respond. Based on interviews and record review, the facility’s policy is for caregivers to respond to call buttons within 10 minutes or less. Based on interviews, it takes staff less than 10 minutes to respond to a call button and if they are busy, other caregivers can be called on to help. Complaint also alleged that staff did not provide services to resident as specified in their care plan. Per interview with Reporting Party, R1 was to get showers on a daily basis per their care plan and status checks throughout the day. According to the Reporting Party, status checks were not done in person. Based on interviews and record review, R1 did ask for a shower every day and was provided one by their 1:1 caregivers as R1’s private caregivers asked the facility staff not to provide care. Complaint alleged that staff did not notify resident's responsible party of changes to R1's care plan. Based on document review and interview, the facility’s Care Coordination Director and Regional Care Director contacted R1’s responsible party and discussed each update to the care plan with the responsible party. Complaint alleged that staff overcharged resident. According to the Reporting Party, R1’s level of care costs were raised from $2,200 to nearly $6,000. Based on document review and interview, R1’s needs changed over time and thus R1 was reassessed by the facility’s Care Coordination Director and Regional Care Director. They notified R1's responsible party of the change who agreed to the change in level of care and cost associated. In addition, based on document review and interview, level of care and monthly charges are explained in the facility's admission agreement. Although the 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 above allegations are unsubstantiated at this time. No deficiencies cited during today's visit. An exit interview was conducted. This report was reviewed with facility representatives and a copy provided.the state’s words, verbatim · CDSS document, Dec 1, 2025 · control 14-AS-20250626124143

Allegation investigated: - Staff financially abused a resident

On 11/10/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in response to the allegation received. LPA met with assistant general manager Armando Prado and explained the purpose of today's visit. During the course of the investigation, interviews were conducted, and documentation is reviewed. Per interview with the general manager in August 2025, and today with the assistant general manager of the facility, the facility does not sign residents up for the services as it was only a referral the facility provided to that company. The person identified in the complaint as being a staff person who financially abused the resident, is in fact not a staff person associated to the facility. The person identified is the owner of an outside company the resident was receiving pet services for. The company is an independent company not tied to the facility and provides services to the general public as well. This situation has been reported to Adult Protective Services and the Long Term Care Ombudsman, San Francisco Police Department, and the Department via incident report. This allegation is unfounded. This agency has investigated the complaint alleging, staff financially abused a resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Nov 10, 2025 · control 14-AS-20251106111837

Type of visit: Case Management - Incident

On 11/10/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit in response to an incident report received on 10/08/2025. LPA met with assistant general manager Armando Prado and explained the purpose of today's visit. According to the incident report received, the resident fell while outside of the facility and hit their head. Resident was brought back to the facility by a good samaritan. The facility called 911 due to the injury to the head and the resident was evaluated at the hospital and the facility notified responsible parties and the primary care physician of the resident. The resident returned to the facility with discharge instructions. LPA reviewed the file of the resident and found that the resident is allowed to leave the facility unassisted. The resident walks on their own and is ambulatory with no walking aids or devices. The resident goes on walks on their own regularly outside of the community. The resident is back in the facility and has recovered back to baseline with no injuries or changes in status. No citations issued. Report is reviewed with Armando and a copy is provided.the state’s words, verbatim · CDSS document, Nov 10, 2025

Type of visit: Case Management - Incident

On 11/6/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with administrator, Matthew Turner and explained the purpose of today's visit. On 10/13/2025, CCL received an incident report from the facility concerning to an incident that happened on 10/10/2025 in which resident #1 (R1) slapped resident #2 (R2)'s as R1 reported that R2 pinched his/her hand. This incident was witnessed by the Memory Care Director who discouraged R1 from hitting another resident. The facility reported the incident to R1 and R2's responsible party. The facility conducted an assessment of R2 and there was no injuries noted. During today's visit, LPA met R1 and R2 and attempted to speak to R1 but he/she did not want to speak to LPA. The administrator stated that both residents are doing well and there were no further aggressive behaviors from both. No deficient is cite. This report is reviewed and discussed with the assistant general manager. A copy is provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Case Management - Incident

On 11/6/2025, Licensing Program Analyst (LPA) Murial Han conducted an announced case management visit to follow up on an incident that was reported by the facility. LPA met with administrator and explained the purpose of today's visit. On 10/13/2025, the facility reported an incident that happened on 10/9/2025 in which Resident #1 (R1)'s responsible party reported to the facility that a monthly rent cashier's check to the facility was deposited by an unknown person. R1's responsible party stated that the check was originally made out to the facility and mailed to the remit address for R1's monthly rent. However, it was altered in the process and the facility never got the payment. During today's visit, the administrator did not have any information as to how the name on the check was altered to an unknown person as the facility does not handle payments locally, all payments are mailed to the remit address for processing. In addition, the administrator does not recognize the unknown person's name on the check. This incident was reported to the Local Law Enforcement and R1's responsible party is currently working with the bank on this matter. LPA reviewed the LIC 500 and did not observe the unknown person's name. No deficient is cite today. This report is reviewed and discussed with the Assistant General Manager and a copy is provided.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Case Management - Incident

On 09/30/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted a case management visit concerning a report of suspected abuse received on 9/22/25. LPA met with administrator Matthew Turner. LPA explained the purpose of today's visit. Regarding the report, an unknown caller contacted resident R1, pretending to be from the facility and requested a money transfer. R1 provided bank information to the caller, and the money was subsequently transferred. LPA conducted an interview with the Administrator and obtained the following information: the facility submitted an incident report to Community Care Licensing (CCL) for review. According to the admission agreement, R1 and her husband—both residing in assisted living—are listed as the responsible parties. The resident’s son accompanied R1 to the facility office to report that she had shared her bank information with an unknown caller. The resident’s daughter also contacted the facility to confirm whether the facility had called R1. The facility confirmed that no such call had been made. The daughter then informed the facility that funds had indeed been transferred to the unknown caller. Facility does not contact residents by phone to collect payments, as all payments are handled through an online portal. Residents received scam calls from outside sources. Staff receive annual training on theft and loss prevention. In response to this incident, a scam prevention notice was also sent to all residents. A copy of the police report was not available, and no report number was provided, as R1 filed the report independently. No additional relevant information or documentation was available at the time of the visit. The LPA requested copies of the resident’s admission agreement (including the Theft and Loss Program notification), the resident’s medical report, care plan, and reassessment. No deficiencies cited today. Report was discussed and a copy of the report is provided.the state’s words, verbatim · CDSS document, Sep 30, 2025

Allegation investigated: - Staff did not safeguard resident's funds

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, and the facility has reported the situation to Adult Protective Services and the Long Term Care Ombudsman, and the Department via incident report. This allegation is unsubstantiated. Based on these observations, the above allegations are 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 allegations are unsubstantiated at this time. This report is reviewed with Michael and a copy is provided on this day. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 26, 2025 · control 14-AS-20250819215313

Allegation investigated: Staff did not ensure that medications are inaccessible to residents in care

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, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights provided. Substantiated Complaint alleges, staff did not administer medication as prescribed. Complaint further indicates that R1 is given an eye drop medication more than the daily prescribed dose. Based upon a review of R1's medication records, LPA found that R1 is prescribed two different eye drop medications, both of which have orders for daily use. One of which is administered once per day and the other administered three times per day. Photo evidence shows that the eye drop medication with an order to administer once per day was left accessible in R1's bedroom. However, based upon sample review of R1's MAR, LPA did not find enough corroborating evidence indicating the facility had incorrectly or over-administered R1's medication. In addition, interview with R1 posed contradicting information towards the allegation. A finding that the complaint allegations, staff did not administer medication as prescribed and staff did not properly manage resident's medication are 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. No deficiency cited.the state’s words, verbatim · CDSS document, May 21, 2025 · control 14-AS-20250306100512

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: May 22, 2025

87465(h)(2) - Incidental Medical and Dental Care. Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This was not met as evidence by:** Based upon review of resident R1 records, LPA found that resident R1 is not able to manage or store their own medicaitons. Additionally, gathered photo evidence shows prescription medicaiton left in R1's bedroom by staff on multiple occassions. This serves as an immediate health & safety risk to resident in care.the state’s words, verbatim · CDSS document, May 21, 2025

Plan of correction: Licensee/Administrator failed to ensure R1's medications were kept safe and not accessible to residents in care. Licensee agrees to conduct a training on protocols for medication storage and administration. Scheduled training date to be submitted to CCLD by POC date 5/22/2025. In addition, completed training signed by all participating staff is to be submitted to CCLD by POC date 5/30/2025.

Type of visit: Required - 1 Year

On 2/27/2025, Licensing Program Analysts (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by General Manager, Matt Turner. The facility currently provides care for 193 residents, 6 of which are receiving hospice services along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common spaces and kitchen and food storage areas were inspected. Fire Extinguishers located throughout the building were found to be charged. Smoke and carbon monoxide detectors and fire safety systems are interconnected with last fire safety inspection completed October 2024 with all corrections completed. Cleaning supplies and other toxins are safely stored in locked closets throughout the facility, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms were found to be in a clean and comfortable condition with lighting & appropriate furnishings and bedding items. Residents were observed to be out in the community during the inspection, interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering a unique variety of activities and outings based on individualized preferences and capabilities. A wide selection of activity supplies and amenities including a gym, pool, large outdoor patio and guest performances are all provided. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis with residents observed to have a positive and personable relationship with staff and General Manager. Continued onto LIC809-C LPA conducted a sample file review for several residents and found all items to be on file including Needs & Service Plans and Medical Assessments to be current. Upon a spot check of staff files, LPA found that caregiver staff have current first aid and annual training, health screenings and TB results on file. Lastly, a spot check of medications was conducted and found that all medication counts and records are in order. Administrator, Deborah Suarez's Administrator Certificate 7008093740 is valid through 5/15/2025 General Manager, Matthew Turner's Administrator Certificate 6074366740 is valid through 1/28/2027 LPA requested the following documents be sent to CCL by COB 3/13/2025: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during today's visitthe state’s words, verbatim · CDSS document, Feb 27, 2025

Allegation investigated: Facility staff not meeting resident needs

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 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.the state’s words, verbatim · CDSS document, Nov 21, 2024 · control 14-AS-20240830083504

Allegation investigated: Facility devices not properly working

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, LPA also found that the pool lift was in the process of repair and awaiting parts for completion. LPA also provided documentation of repair services in process. LPA found that the facility is aware of the devices in need of repair and have taken initiative to repair devices. Lastly, upon final inspection, all elevators and pool lift were in operating condition. Due to contradicting information gathered and a lack of corroborating evidence, the allegation is found to be unsubstantiated. A finding that the complaint allegations, facility devices not properly working 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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 14, 2024 · control 14-AS-20240830083504

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 did not do a proper assessment - Staff are charging residents for services not rendered - Staff are not following the admission agreement

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 the admission agreement, the agreed upon rates at time of admission signing was in place until the facility discovered after signing that both residents needed additional services added to their care plans which increased the rate at time of signing. Assessments were done at the time of signing but new services were needing to be added and new physicain's reports and service plans were needed to address the additional changes. These allegations are unfounded. This agency has investigated the complaint alleging, "Staff did not do a proper assessment, Staff are charging residents for services not rendered, and Staff are not following the admission agreement". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with Matt Turner and a copy is provided. Unfoundedthe state’s words, verbatim · CDSS document, Sep 5, 2024 · control 14-AS-20240709153531

Allegation investigated: Due to lack of staffing, resident calls bells are not answered timely

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 met, therefore the above allegation is found to be substantiated. Substantiated The deficiency cited on the following page is in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8: This report is provided and reviewed with facility representative and a copy of this report must be made available for public review upon request. Appeal rights discussed and provided.the state’s words, verbatim · CDSS document, May 24, 2024 · control 14-AS-20231214102829

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jun 10, 2024

87468.1(a)(2): Personal Rights: Residents in all residential care facilities for the elderly shall have all of the following personal rights:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement was not met in 3 out 3 cases in which staff did not respond to a resident's call button in a timely manner. This is a potential health and/or safety risk to persons in care.the state’s words, verbatim · CDSS document, May 24, 2024

Plan of correction: Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Type of visit: Required - 1 Year

On February 16, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the unannounced Annual 1-year required Annual Inspection. LPA Calandra was greeted by Collin Hardwick, Concierge. Deborah Suarez, Assistant General Manager and Shirley Cheung, Care Coordination Director, and Matthew Turner, General Manager arrived later. LPA Calandra toured the physical plant. This is a fourteen story building that consists of 144 bedrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last inspected on January 30, 2024. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The outdoor space was clear from obstructions. No accessible bodies of water or hazards were observed. The facility does not handle any cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. LPA Calandra reviewed 5 resident files and 5 staff files. All were observed to be complete. LPA Calandra also interviewed 3 staff and 3 residents. All knives, sharp objects, soaps, detergents, and medications were observed to be locked and in-accessible to persons in care. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records(CSMR) kept at the facility. LPA Calandra received the following documents at the facility: -Trainings completed by Assistant General Manager, Deborah Suarez -Administrator's Certificate for Deborah Suarez -Updated LIC 500 reflecting all staff No deficiencies were cited during today's visit. A copy of the report was reviewed with Deborah Suarez, Assistant General Manager, Shirley Cheung, Care Coordination Director, and Matthew Turner, General Manager and a copy left at the facility.the state’s words, verbatim · CDSS document, Feb 16, 2024