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STATE OF CALFORNA HEALTH AND HUMAN SERVICES AGENCY aurora deranruen of soca. services FACILITY EVALUATION REPORT SE gino, TRAEOER Av, STE 0 FACILITY NAME: SAN FRANCISCO RCFE FACILITY NUMBER; 385600300 ADMINISTRATOR:ADELA MORALES FACILITY TYPE: 740 ADDRESS: 887 POTRERO AVENUE TELEPHONE: (618) 206.6402 city: ‘SAN FRANCISCO STATE:CA ZIPCODE: 94110 capac: 59 CENSUS:0 DATE: 10/02/2018 TYPE OF VISIT: Offce ANNOUNCED TIME BEGAN: 09:30 AM MET WITH: Und Sims, KelyHramoto, len Lew. Roland aye COMPLETED: ane NARRATIVE ‘noncompliance meeting was conducted in Licensing office fo Glscuss the noncompliance concems, regarding Acceptance and Retention, Observation of Residents, Reappraisal, Incidental Medical and Dental Gare Services, Basic Services, and Criminal record Clearance. Refer to Noncompliance summary dated October 2, 2018. The meeting was conducted by RM Vivien Helbling, LPM Ali Zebila, and LPA Faye Bremer. ‘The meeting was attended by Director of San Francisco Behavioral Health Center Linda Sims, Director of San Francisco Health Network Transitions Kelly Hiramoto, Director of SF Health Network Roland Pickens, and Deputy City Attorney Glenn Levy. ‘The compliance plan was discussed and final compliance plan from Licensee shall be received in office October 16, 2018. ‘This report was reviewed with Director of San Francisco Behavioral Health Center Linda Sims, Director of San Francisco Health Network Transitions Kelly Hiramoto, and Deputy City Attomey Glenn Levy. 7 2 3 4 5 6 7 8 9 10 " 12 13 14 18 16 7 18 19 20 21 22 23 24 25. ‘SUPERVISt ian fel LICENSING EVALUATOR NAME: Faye Bremer LICENSING EVALUATOR SIGNATURE: DATE: 10/02/2018, acknowledge receipt of this form and understand my licensing appeal rights as explained and received. FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/02/2018 ucan (ras 0608) STATE OF CALIFORIA. HEALTH AND HUMAN SERVICES AGENCY euurona oerantuenr oF soca. semvces NONCOMPLIANCE CONFERENCE SUMMARY ‘SCLO Regional Oe, #51 TRAEGER AVE, SUITE 260, Siatanuno,caseoce RE RD ROE OF FR $$ $$ ‘SAN FRANCISCO RCFE 887 POTRERO AVENUE ‘SAN FRANCISCO, CA 94110 _FROTTY LICENSE NONBER EFFECTIVE DATE OF LICENSE [LICENSE CAPACITY STATUS FACIE 1WFE— 385600399 osiogi2014 59 3 740, TCENSEE WANES SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH NAME AND FACILITY NUMBER OF OTHER COMMUNITY CARE, CHILD DAY CARE, RESIDENTIAL CARE, FACILITIES FOR THE ELDERLY, OR HEALTH FACILITIES LICENSED TO OR OWNED BY APPLICANT(S) WITHIN THE LAST FIVE YEARS. FACILITY NAME: FACILITY NUMBER A |San Francisco Adan Residential Faciiy SEGRTOOTS 8. c. 5. E F DATE OF CONFEREN NSING PROGRAM ANALYST: ] HOENSING PROGRAMA MANGER 10/02/2018, Faye Bremer Al Zebila Present at meeting: NAME TITLE Vivien Hetoling Regional Manager Ali Zebila Licensing Program Manager Faye Bremer Licensing Program Analyst Linda Sims Director of SF Behavioral Health Center Kelly Hiramoto irector SF Health Network Transitions Roland Pickens rector of SF Health Network Glenn Levy Deputy City Attomey ‘cars ras 1298) (PUBLIC) Page: ot ‘STATE OF CALIFORWA- HEALTH ANO HUMAN SERVICES AGENCY ‘CALIFoROA DEPARTMENT OF Social SERVICES oumtunet cane conse ISIN NONCOMPLIANCE CONFERENCE SUMMARY - —¢2.2-edena ome a1 reaecen ave, sure t0 PAGE 2 RR ADRESS OF FRO ‘SAN FRANCISCO RCFE 887 POTRERO AVENUE SAN FRANCISCO, CA 94110 "FRCILITY LICENSE NOWSER [EFFECTIVE DATE OF LICENSE” [UCENSE CAPACITY. —SYRTUS" FRET T¥PE— 385600399 9108/2014 58 3 740 WOERSEE WANES SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH ‘This Noncompliance Conference was called to discuss the following issues or deficiencies: 1 Facility was licensed on 09/08/2014, Violations issued recently under Title 22, Div. 8, Chapter 8 include: 2 Observation of the Resident, Criminal Record Clearance, Basic Services, Reappraisals, Incidental Medical and 3 Dental Care. 4 5» On 9/11/2018 citation issued under 87455(c)(3)(B) - Acceptance and retention. It was found that due to 6 facility's failure to reassess resident, facility retained resident with dementia. Facility does not have a 7 Dementia Plan of Operation 8 9 ‘® On 8/23/2018 and 7/26/2016 citations issued under 87466 - Observation ofthe Resident. 10 # Ri left the facility on 5/19/2018 and was found deceased on 5/30/2018. The Department discovered " that Licensee failed to ensure observation of resident's changes in mental ability were documented and 2 brought to the attention of the resident's physician to ensure resident was provided with appropriate 13 care and supervision, 14» 0n7/26/2016 citation issued under 87466 for a Substantiated complaint. It was found that facility 18 failed to provide appropriate assistance to meet resident's medical needs. 16 17 © 0n 8/23/2018 and 7/26/2016 citations issued under 87463(a) - Reappraisals. 18 © 0n8/23/2018, it was found that due to lack of reappraisal, facility failed to address R1's needs, resulting 19 in R1 continuing to leave facilty unassisted. Licensee failed to folow up with Physician to ensure R's 20 Physician's Report and appraisal was updated to reflect the changes in condition, 21 0n 7/26/2016 citation issued under 87463(a) for a Substantiated complaint, It was found that facility 22 failed to update appraisals to document changes in resident's conditions, 23 24 © 02/6/2017 citation issued under 87355(e)(2) for a Substantiated complaint for Criminal Record Clearance 25. Itwas found that St was fingerprint cleared, but nt transfered fo he facity number prior o werking 27 « On 7/26/2016 citation issued under 87464(0(3) for a Substantiated complaint for Basic Services. It was 28 found that facity staff felled to assist resident resulting to neglect ofa resident with poor condition on hands and feet, 30 31 « On 7/2/2015 citation issued under 87465(a)(5) for incidental Medical and Dental Care Services. It was 32__found that R1 did not not receive medications for 18 days due to MediCal not being renewed on time, LUCENSEE SIGNATURE DATE! 9107/2018 MANAGER SIGNATURE ATE 09/07/2018 acer ras) -1298)-(uBLIC) Page 2046 STATE OF CALIFORNA-MEALTH AND HUMAN SERVICES AGENCY CAUFORWA DEPARTIENT OF SOCIAL SERVICES ‘Commun? eae eNsNG OMBION NONCOMPLIANCE CONFERENCE SUMMARY - s