Alma Via of San Francisco

Type of visit: Required - 1 Year

On 10/07/2025, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced annual inspection visit. LPA met with the executive director Cleitus Jones and explained the purpose of today's visit. There are currently 127 residents in the facility during this inspection. This is a multi-level facility, age range 60 years old and over. 140 residents may be non-mbulatory residents shall not be housed above the 2nd story. Dementia units are on the 1st and 2nd story. Units 316-326 are on the 2nd story. Hospice waiver approved for 35 residents. There are currently 9 residents under hospice care today. This facility has three secured memory care areas. The physical plant was toured inside and outside of the facility to ensure the safety of the clients. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored and locked and secured in the kitchen. Perishable and non-perishable food supplies are observed as in place. Kitchen grade fire extinguisher is observed as in place and with an inspection date of 07/26/2025. First aid kits are observed as complete with required items as observed. Medications are observed to be locked in medication rooms in memory care areas and in assisted living. Medication carts are locked and used to disperse medication to residents through out the community. LPA reviewed resident medications at random and observed them as current and stored correctly including medications in refrigeration units. LPA observed that there are multiple fire extinguishers in place on each floor with an inspection date of 07/26/2025. Smoke detectors, carbon monoxide detectors, and full fire sprinkler system is observed in place through out the facility. Central heating and air conditioning is in place. Continued on next page... Page 2 Laundry areas are also observed as fully operational clean and organized. Detergents are dispersed through push button automation systems. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Evacuation chairs are in place in emergency exit stairwells as well. Last emergency/disaster drill was conducted in 09/26/2025. Water temperature was measured at 105F in resident rooms 318B, 320B, and 240B. Room 216 was tested at 110F. Cleaning supplies are observed to be inaccessible to residents in care. Resident rooms are observed at random. LPA observed 5 resident rooms, and all are free of odors and contained all the required furniture per regulatory recommendations. Resident linen supplies are observed as in place stored in various closets and in laundry rooms through out the facility. LPA reviewed five staff files and six resident files during today's inspection and all files are observed as current. Staff are actively conducting training via Relias and it is observed as current. Administrator certificate is current expiring 04/04/2026. No citations issued. Report is reviewed with Cleitus Jones and a copy is provided on this day.the state’s words, verbatim · CDSS document, Oct 7, 2025

Type of visit: Case Management - Incident

On 8/19/2025, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced case management-incident. LPA met with Executive Director (ED) Cleitus Jones and explained the purpose of the visit. The visit is regarding about the SOC 341 submitted by the facility to Licensing. On 8/12/2025, a resident (R1) was restrained to his/her wheelchair with a gait belt by two staff members. Another staff member (S2) who witnessed it immediately removed the restraint. The two staff members were interviewed and admitted to using the belt to prevent a fall as said resident was restless. Facility has since terminated the two staff members. LPA interviewed S2 and he/she stated that the incident was reported to her by another staff (S1). S2 checked R1 and there were no injuries or bruises. LPA also interviewed S1 and he/she mentioned that when he/she saw R1 with a gait belt, he/she removed it right away and told the two staff members to not use the restraint. ED has also mentioned that there is an overlap of staffing as the night shift were still working around the time of the incident. Facility conducted an in service training for staff regarding the risks of restraining a resident and reporting requirements, after the incident happened. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Report is reviewed and a copy of the report and appeals rights are provided.the state’s words, verbatim · CDSS document, Aug 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(5) · Plan of correction due date: Aug 20, 2025

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal... Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This was not met as evidenced by: Based on interviews, two staff member restrained R1 with a gait belt limiting the use of R1s hands which poses an immediate health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 19, 2025

Plan of correction: Licensee has already corrected the deficiency by doing an in-service training about reporting requirements and restraints and have since terminated the two staff members.

Type of visit: Case Management - Other

On 5/29/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit to deliver an Amended report for a report delivered on 4/30/2024. LPA Calandra was greeted by Cleitus Jones, Executive Director and explained the purpose of the visit. This complaint was reopened due to additional information being received by the Department. A new finding was delivered to the Licensee on 4/17/2025. During today's visit, LPA Calandra reviewed the amended report with the Administrator and provided a copy of the report. An exit interview was conducted and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, May 29, 2025

Type of visit: Case Management - Other

On 4/17/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating a case management visit and was greeted by Executive Director, Cleitus Jones. The purpose of the case management is to address corresponding complaint investigation report number 14-AS-20240426082005. Upon further review of investigation evidence, the original complaint report (LIC9099) dated 4/2/2025 has been amended as subjected to substantiated findings. Complaint alleges facility staff did not provide proper notice of rate increase for resident (R1). Upon further review of R1’s invoices, payment ledger and rate of increase notice dated 7/31/2020; effective 10/1/2020, LPA identified inconsistencies of fee amounts charged that do not match the addendum rate. The facility also failed to include modified conditions and rate structure when in the notice in comparison to the ledger. Upon further review of R1’s invoices, payment ledger and rate of increase notice dated 4/30/2021; effective 7/1/2021, LPA identified inconsistencies of fee amounts charged that do not follow the addendum rate modified conditions and rate structure stated in the notice when in comparison to the ledger. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Apr 17, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87507(g)(4) · Plan of correction due date: May 1, 2025

87507(g)(4) Admissions Agreements - Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. This requirement was not met as evidence by:** Based upon review of R1’s records of rate increase notices and payment ledger and invoices, LPA found that the facility failed to provide proper notice of rate increase that identifies modification conditions and rate structure changes in documented noticed dated 7/31/2020 and failed to follow modification conditions in documented notice dated 4/30/2021. This serves as a potential health, safety and personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Apr 17, 2025

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure compliance with all terms and conditions set forth in the admissions agreement/rate addendums for resident R1. Licensee/administrator are to also determie how the facility will reconcile for R1. Plan to be submitted to CCLD by POC date 5/1/2025.

Type of visit: Case Management - Other

On 4/11/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of initiating a case management visit and was greeted by Executive Director, Cleitus Jones. The purpose of the case management is to discuss and request resident (R1) records upon additional findings from LPA review of investigation evidence. No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Apr 11, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 0 · Plan of correction due date: Apr 12, 2025

****THIS IS AN AMENDMENT**** to original report dated 4/11/2025. LPA did not determine a deficiency during visit. Citation removed. No citation issued.the state’s words, verbatim · CDSS document, Apr 11, 2025

Allegation investigated: Prior to admission staff did not provide resident or resident's authorized person with an appraisal of the resident's individual service needs Staff did not provide records to resident or resident's authorized person upon request

On 4/2/2025, LPA Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Cleitus Jones. LPA interviewed staff, resident and outside parties and reviewed resident records during the course of the investigation. Complaint alleges prior to admission staff did not provide resident or resident's authorized person with an appraisal of the resident's individual service needs. Upon review of resident records, LPA determined that prior to resident (R1’s) admission, the facility had completed an appraisal for R1. LPA interviewed R1 who stated that they did not have concerns of the facility not completing or providing their care plan. R1 indicated that the facility is meeting their needs and is very satisfied with the care provided. In addition, R1 can determine their own health needs and does not have or require a responsible party for health needs and decisions. Continued onto LIC9099-C Unsubstantiated R1 indicated to speak with their responsible party (I1). Upon interview with I1 LPA received contradicting information towards the allegation. Due inconsistent information gathered and to a lack of corroborating evidence, the allegation is found to be unsubstantiated. Complaint alleges staff did not provide records to resident or resident's authorized person upon request. LPA interviewed resident (R1) who stated that they did not have any concerns or report that the facility was not providing records. R1 can determine their own health needs, request their own medical and care records and stated that they have not requested any documents from the facility. R1 indicated to speak with their responsible party (I1). Upon interview with I1 LPA received contradicting information towards the allegation. Due inconsistent information gathered and to a lack of corroborating evidence, the allegation is found to be unsubstantiated. A finding that the complaint allegation alleges facility staff did not provide proper notice of rate increase 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. No deficiency cited.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 14-AS-20250203162006

Allegation investigated: Facility staff did not provide proper notice of rate increase

**This report is an amended version of original LIC9099 dated 4/2/2025** On 4/17/2025, LPA Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Cleitus Jones. LPA interviewed staff, resident and outside parties and reviewed resident records during the course of the investigation. Complaint alleges facility staff did not provide proper notice of rate increase for resident (R1). Reporting party indicated the following dates: 7/31/2020, 4/30/2021, 4/30/2022, 1/27/2023, 1/30/2024, with an additional noted increase on 8/1/2020. Upon a review of resident (R1) records, LPA gathered all dated notifications of rate increases on file. Continued onto LIC9099-C Substantiated **This report is an amended version of original LIC9099-C dated 4/2/2025** Upon further review of the alleged rate increase on 8/1/2020, LPA found that upon R1’s admission, a move-in confirmation record was completed and indicated R1’s move-in level of care rate. The document was signed by R1’s financial responsible party (I1) agreeing to the rate. Based on a review of R1’s payment ledger and invoice, LPA found that the facility provided an adjusted rate for R1 upon admission. The facility began charging R1 the original agreed upon move-in level of care rate as of 8/1/2020. Based on LPA findings, this alleged date of 8/1/2020 is not determined as a rate increase. Upon further review of R1's payment ledger corresponding invoices and rate of increase notice dated 7/31/2020; effective 10/1/2020 LPA identified inconsistencies of fee amounts charged that do not match the addendum rate. The facility also failed to include modified conditions and rate structure in the notice when in comparison to the ledger and invoice. It was found that effective 10/1/2020, the monthly rate increased to $4885. However, ledger indicates a monthly rate of $5595 with a $710 market adjustment applied. This information of modification and rate structure was not clearly indicated on the notice dated 7/31/2020 or corresponding invoice which is determined an improper notice. Upon further review of R1’s payment ledger corresponding invoices and rate of increase notice dated 4/30/2021; effective 7/1/2021, LPA identified inconsistencies of fee amounts charged that do not follow the addendum rate modified conditions and rate structure stated in the notice when in comparison to the ledger. It was found that effective 7/1/2021, the monthly rate increased to $5700 with an approved monthly fee discount of $710. However, ledger and invoice does not have any indication of the discount applied based on the notice dated 4/30/2021 which is determined an improper notice. Allegation, facility staff did not provide proper notice of rate increase 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 separate 809-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. Exit interview conducted and appeal of rights provided. Citation issued on corresponding Facility Evaluation Report LIC809.the state’s words, verbatim · CDSS document, Apr 2, 2025 · control 14-AS-20240426082005

Allegation investigated: Lack of supervision resulted in resident eloping from facility

On 10/15/2024, Licensing Program Analysts (LPA's) Tobola & Jian arrived unannounced for the purpose of initiating complaint investigation and was greeted by Executive Director, Cleitus Jones. LPA toured the facility, interviewed Executive Director, gathered resident records and made observations during the course of the investigation. Complaint alleges, lack of supervision resulted in resident eloping from facility. Based upon interviews with Executive Director, it was found that resident (R1) had eloped from the facility during the overnight hours of 9/28/2024. It was found that staff (S1) had been asleep during the incident had not properly supervised residents resulting in R1 exiting the facility unsupervised. Upon review of R1's records, it was found that R1 is diagnosed with dementia, has wandering behavior and is not allowed to leave the facility unassisted. Allegation, Lack of supervision resulted in resident eloping from facility 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. Exit interview conducted and appeal of rights provided. Substantiatedthe state’s words, verbatim · CDSS document, Oct 15, 2024 · control 14-AS-20241007145518

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 16, 2024

Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidence by: Administrator failed to prevent resident (R1) from eloping the facility. Based upon interview with Administrator, it was found staff (S1) was asleep during the incident, and not properly supervised resident (R1). Record review shows R1 is diagnosed with dementia, at wander risk and unable to leave the facility unassisted. This serves as an immediate health & and safety risk.the state’s words, verbatim · CDSS document, Oct 15, 2024

Plan of correction: Administrator has implemented corrective actions for staff (S1) leading to termination of position. In addition, Administrator has conducted an in-service training for all staff on elopement procedures and provided copy of training log to CCL. Continuing elopement training will be conducted on a weekly basis for an additional month to ensure compliance. Additional care measures for R1 were also implemented to prevent future elopement. Deficiency cleared at the time of visit.

Type of visit: Required - 1 Year

On 10/11/2024, Licensing Program Analysts (LPA's) Tobola Jain conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Plant Operations Director, Ping Huang & Executive Director, Cleitus Jones. The facility currently provides care for 136 residents, 12 of which are receiving hospice services, along with multiple designated memory care units. LPA's 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 areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor, kitchen and common spaces were found to be charged with last inspection date of 7/15/2024. Smoke and carbon monoxide detectors were present with fire safety Inspection completed 7/3/2024 indicating all fire safety devices and systems are in order. Emergency drills are conducted on a monthly basis with the last drill performed on 9/28/2024. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping carts all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water at faucets accessible to residents measured between 108.1 degrees F and 114.4 degrees F and within regulation. Residents that were out in the community the inspection were observed 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 activities based on individualized preferences and abilities. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents are encouraged to participate in activities, well observed in both assisted living and memory care units. Residents were also observed to have a positive and personable relationship with staff and Executive Director. There are multiple patios for resident use, all equipped with appropriate shading Continued onto LIC809-C LPA's conducted a sample file review for residents and found all items including needs & service plans and medical assessments up to date. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training on track for completion. However, staff (S1) does not have health screening report on file. Technical Violation issued. Lastly, A spot check of medications including narcotic was conducted and found that all medication counts and records are in order. Cleitus Jones's Administrator Certificate 6069222740 is currently active through 4/4/2026. LPA requested the following documents be sent to CCL by COB 10/25/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance No deficiencies cited during today's visit.the state’s words, verbatim · CDSS document, Oct 11, 2024

Allegation investigated: Resident sustained injuries due to staff neglect Staff did not ensure facility transport vehicle was not in disrepair

On 9/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Cleitus Jones. LPA toured the facility, interviewed staff, gathered facility documents and made observations during the course of the investigation. Complaint alleges resident sustained injuries due to staff neglect. Based upon interviews with Executive Director and staff (S1) it was found that S1 had provided assistance to resident (R1) during transportation to an appointment on 8/22/2024. The facility van wheelchair lift was not in proper electronic functioning order but is also equipped with a manual hand crank lever located inside the vehicle. S1 stated that they assist residents into the wheelchair lift based on transportation practices for wheelchair assistance by placing residents facing forwards and outside the vehicle. During the event, S1 had properly loaded R1, facing forwards towards the outside of the vehicle while S1 had operated the manual lift from the inside of the vehicle. It was found that R1 had sustained minor injury from falling forward from the wheelchair. However, there is a lack of corroborating evidence to prove that the incident was due to intent or neglect as staff were following proper manual device transportation protocols, therefore the allegation is unsubstantiated. Continued onto LIC9099-C Unsubstantiated Complaint alleges staff did not ensure facility transport vehicle was not in disrepair. Based upon interviews with Executive Director, staff (S1) and LPA observations, it was found that the facility vehicle wheelchair lift had not been in electronic operating condition for a period of time. The facility was aware of the device needing repair and had documentation of cost quotes for repairs. LPA observed lift with staff (S1) showing that the lift does not electronically retract back into the vehicle. However, the lift is equipped with a manual hand crank to operate in case of electronic failure. Although the van lift electronic system is not in repair, the van lift is still equipped to properly execute its function. Due to contradicting information gathered and a lack of corroborating evidence, the allegation is found to be unsubstantiated. A finding that the complaint allegations, resident sustained injuries due to staff neglect and staff did not ensure facility transport vehicle was not in disrepair 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.the state’s words, verbatim · CDSS document, Sep 20, 2024 · control 14-AS-20240823163924

Type of visit: Case Management - Incident

On 9/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following with case management regarding complaint investigation and incident involving resident (R1) and was greeted by Executive Director, Cleitus Jones. On 8/22/2024, R1 had been assisted onto the facility van for an appointment by staff (S1). It was found that the facility van wheelchair lift was not in proper electronic functioning order but is also equipped with a manual hand crank lever located inside the vehicle, that still provides lifting function in case of electronic failure. S1 stated that they assist residents into the wheelchair lift based on transportation practices for wheelchair assistance by placing residents facing forwards and outside the vehicle. During the event, S1 had properly loaded R1, facing forwards towards the outside of the vehicle while S1 had operated the manual lift from the inside of the vehicle. During the lifting process it was identified that R1 had sustained minor injury from falling forward from the wheelchair but not due to intent or neglect. During LPA observation of wheelchair lift, it appeared that the manual crank causes a jerking motion which was a potential factor in R1 moving forward and sustaining a fall from the lift with minor injury Based on interviews with staff, R1 was not equipped with a standard wheelchair device with larger rear wheels but instead equipped with a foldable wheelchair with a set of smaller swiveling wheels, with less or no leverage towards the back of the wheelchair. Although not due to intent or neglect, staff did not ensure that R1 was provided safe accommodations and equipment or additional support to prevent R1 from sustained injury. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.the state’s words, verbatim · CDSS document, Sep 20, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 27, 2024

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidence by: Based upon interviews with Executive Director, staff (S1), review of facility records and LPA observation, facility failed to ensure resident has safe accommodations and equipment as resident (R1) sustained injury from falling off wheelchair lift during transport. This serves as a potential health & safety & personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 20, 2024

Plan of correction: Facility agrees to provide written statement of how they will remain in compliance regarding residents being accorded safe accommodations and equipment involving facility vehicles by POC date 9/27/2024.