StarlynnCare

California · San Francisco

Coterie Cathedral Hill

RCFE

A Residential Care Facility for the Elderly (RCFE) is a non-medical residential care home licensed by California CDSS under Health & Safety Code §1560. Residents receive assistance with daily living activities such as bathing, dressing, meals, and medication management in a home-like setting. RCFEs are not hospitals or skilled nursing facilities — they do not provide round-the-clock medical care.

1001 Van Ness Avenue · San Francisco, 94109

Quick facts

Licensed beds260
Memory careYes
Last inspectionDec 2025
Last citationApr 2026
Operated byVan Ness Opco Tenant Llc; Atria Management Company

Inspection comparison

Updated May 1, 2026

Compared to 80 California RCFE facilities of similar size, over the last 36 months.

Source: California Department of Social Services, Community Care Licensing Division. View raw inspection records →

Peer comparison

Percentile vs 80 similar California CA / rcfe_general / xl beds facilities · higher = better

Severity
6th

Weighted citations per bed

Repeats
100th

Repeat deficiencies as share of total

Frequency
5th

Deficiencies per inspection

Tick mark at 50% = peer median

Citation severity over time

↑ worsening

Weighted severity score per month · 24 months

Jun 24peer medianMay 26

Weighted score (24mo)

20

Last citation

Apr 26

Finding distribution

3 total · 36 months

Scope × Severity (CMS A–L)

IsolatedPatternWidespreadJKLG3HIDEFABCSev 4 · IJSev 3Sev 2Sev 1

View inspections & citations

The rules that apply to this facility

California Title 22 requirements for this facility, with the specific regulation and a suggested question for each.

What dementia-care training must staff complete?22 CCR §87705 / HSC §1569.625

Because this facility markets dementia or Alzheimer's care, state law mandates higher training standards:

  • 12 hours initial dementia training — 6 hours before a staff member works independently with residents, 6 more within the first 4 weeks.
  • 8 hours annual dementia in-service — required every year thereafter.
  • Administrator CE — the administrator must include 8 hours of dementia-specific continuing education in every 2-year recertification cycle.

Training must cover individualized care plans, behavioral expressions, appropriate supervision, and the facility's dementia care philosophy.

Ask on tour: Ask how dementia training records are kept — families may request documentation.

How many staff must be on duty overnight?22 CCR §87415

Based on 260 licensed beds:

1 awake caregivers on duty overnight, one on-call caregiver physically on premises, and one additional on-call caregiver.

State law adds one awake caregiver for each 100 residents above 200.

Violation pattern to watch for:A facility that documents a staff member as "on call" but with that person physically off-site — when the law requires on-premises presence — is in violation of this section.

Ask on tour: Ask the facility to walk you through their overnight staffing plan and confirm whether on-call staff are on premises or off-site.

What health conditions can this facility legally accept or refuse?22 CCR §87612–87615

Restricted — allowed with physician order + care plan

  • Supplemental oxygen
  • Insulin and injectable medications
  • Indwelling or intermittent catheters
  • Colostomy / ileostomy
  • Stage 1 and Stage 2 pressure injuries
  • Wound care (non-complex)
  • Incontinence
  • Contractures

Prohibited — facility must refuse or discharge

  • Stage 3 or Stage 4 pressure injuries
  • Feeding tubes (PEG, NG, or J-tube)
  • Tracheostomies
  • Active MRSA or communicable infections requiring isolation
  • 24-hour skilled nursing needs
  • Total ADL dependence with inability to communicate needs

A hospice waiver (HSC §1569.73) can allow continued care for residents on hospice who would otherwise fall into a prohibited category.

Ask on tour: Ask whether your loved one's specific care needs are restricted or prohibited, and what the facility's process is if needs change after admission.

What must this facility report to the state — and how fast?22 CCR §87211 / WIC §15630
  • ImmediateElopement, fire, epidemic outbreak, or poisoningImmediately
  • 2 hoursAbuse with serious bodily injury2-hour phone report + 2-hour written report — to the California Department of Social Services (CDSS), Adult Protective Services, and law enforcement
  • 24 hrsAbuse without serious bodily injuryWithin 24 hours
  • Next dayDeath of a residentPhone by next working day; written within 7 days
  • Next dayInjury requiring medical treatment beyond first aidPhone by next working day; written within 7 days
  • WrittenBankruptcy, foreclosure, eviction, or utility shutoff noticeWritten notice to CDSS and residents — $100/day penalty (max $2,000) for failure

Your enforcement lever:Incidents that aren't reported on time are themselves a separate violation. If you believe a reportable event wasn't filed, you can submit a complaint directly to the California Department of Social Services (CDSS).

How does CDSS enforce these rules?22 CCR §87755–87777 / HSC §1569.58
  1. 1Notice of DeficiencyWritten citation with a correction deadline. Facility must submit a Plan of Correction.
  2. 2Civil PenaltyStarts at $50/day for non-serious; $150/day for serious deficiencies — immediately, with no grace period. Repeats escalate to $150 first day + $50/day, then $1,000 first day + $100/day.
  3. 3Suspension of AdmissionsFacility cannot accept new residents until violations are corrected.
  4. 4Temporary Suspension or RevocationEmergency suspension for imminent danger; full revocation after administrative hearing.
  5. 5Exclusion OrderAdministrator and operator can be barred from all CDSS-licensed facilities — not just this one.

See how these rules have been applied to this specific facility:

View state inspection record and citations

State records

California Dept. of Social Services · Community Care Licensing
License number
385601116
License type
RESIDENTIAL CARE ELDERLY
License status
LICENSED
License expires
Not yet indexed
Licensed beds
260
Operator
Van Ness Opco Tenant Llc; Atria Management Company

Inspections & citations

28

reports on file

4

total deficiencies

3

Type A (actual harm)

ComplaintApril 1, 2026· SubstantiatedType A
1 deficiency

Inspector: Murial Han

Inspector notes

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

Type ACCR §87468.1(a)(3)

Regulation

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

Inspector finding

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.

Other visitDecember 8, 2025
No deficiencies
Inspector notes

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.

Other visitDecember 1, 2025· Unsubstantiated
No deficiencies

Inspector: John Calandra

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Inspector notes

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.

Other visitNovember 10, 2025
No deficiencies
Inspector notes

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.

ComplaintNovember 10, 2025
No deficiencies

Inspector: Jaime Vado

Other visitNovember 6, 2025
No deficiencies
Inspector notes

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.

Other visitNovember 6, 2025
No deficiencies
Inspector notes

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.

InspectionSeptember 30, 2025
No deficiencies
Inspector notes

On 09/30/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted a case management visit concerning a report of suspected abuse re ceived 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. L PA 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.

ComplaintAugust 26, 2025· Unsubstantiated
No deficiencies

Inspector: Jaime Vado

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

ComplaintMay 21, 2025· MixedType A
1 deficiency

Inspector: Dominic Tobola

Inspector notes

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.

Type ACCR §87465(h)(2)

Regulation

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,

Inspector finding

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.

InspectionFebruary 27, 2025
No deficiencies

Inspector: Dominic Tobola

Inspector notes

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 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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 visit

ComplaintNovember 21, 2024· Unsubstantiated
No deficiencies

Inspector: Dominic Tobola

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Inspector notes

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.

ComplaintNovember 14, 2024· Unsubstantiated
No deficiencies

Inspector: Dominic Tobola

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

ComplaintSeptember 5, 2024
No deficiencies

Inspector: Jaime Vado

ComplaintMay 24, 2024· Substantiated
Citation on file

Inspector: John Calandra

Substantiated — CDSS found a violation and issued a citation. Full citation details are on file with the state.

Inspector notes

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.

Other visitFebruary 16, 2024
No deficiencies

Inspector: John Calandra

Inspector notes

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

ComplaintOctober 31, 2023· Unsubstantiated
No deficiencies

Inspector: John Calandra

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Other visitOctober 25, 2023
No deficiencies

Inspector: John Calandra

Inspector notes

On October 25, 2023, Licensing Program Analyst(LPA), John Calandra and Licensing Program Manager(LPM), Cara Smith arrived at the facility to follow up in regards to an incident report received on September 21, 2023 regarding a resident who left the facility unattended. LPA Calandra and LPM Smith were greeted by Shirley Cheung, Care Coordination Director, Sarah Laloyan, Senior Vice President of Operations, and Deborah Suarez, Assistant General Manager and explained the purpose of their visit. Shirley Cheung and Sarah Laloyan, informed the LPA and LPM that the resident had left the facility with other residents for a community walk with their spouse. The resident came back to the community and notified the front desk staff that they would like to continue their walk. The resident did not sign in or out via the Accushield system.This is not considered an abnormal practice based on an interview with Deborah Suarez, Assistant General Manager. LPA Calandra and LPM Smith reviewed and collected several documents including the resident's LIC 602, list of activities for the day, notes regarding the incident, Absentee notification plan, etc. At this time, there are no deficiencies cited. A copy of this report was reviewed with Shirley Cheung, Care Coordination Director, Sarah Laloyan, Senior Vice President of Operations, and Deborah Suarez, Assistant General Manager and left at the facility.

Other visitAugust 28, 2023
No deficiencies

Inspector: Grace Donato

Inspector notes

Amended Report On 8/28/2023, Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning a report of suspected abuse received on 8/7/23. LPA met with Shirley Cheung, Care Coordinator Director & Deborah Suarez, Assistant General Manager. LPA explained the purpose of today's visit. In regard to the report, resident (R1) mentioned that a private duty aide (PDA) sexually abused him/her. Based on record reviews & interviews, in the admission agreement, pages 6-7 pertaining to Private Duty Aides, Outside Services, R1 is allowed to hire, but hired PDA is to follow rules in the community. The PDA is fingerprinted through the agency. PDA was removed from the facility when the report was made. Currently, facility has suggested to residents to hire from the facility's preferred agencies. Document to be submitted LPA regarding records for the Private Duty Aide. No deficiencies cited today. Report was discussed and a copy of the report is provided.

ComplaintAugust 23, 2023
No deficiencies

Inspector: Jaime Vado

Inspector notes

Page 2 - LIC9099 Positive residents are isolated in their rooms and visitation guidelines are in place requiring visitors to wear N95 masks and face shields if visiting. Staff members in memory care are observed wearing N95 masks and face shields during tour. Notifications to family members are going out on this day due to DPH outbreak status being declared. No staff have tested positive at this time. Facility is abiding by current Provider Information Notification updates at this time. This allegation is unfounded. This agency has investigated the complaint alleging, Staff did not comply with infection control practices resulting in a H&S risk . 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. No citations issued. Report is reviewed with Deborah Suarez.

ComplaintJuly 26, 2023· Unsubstantiated
No deficiencies

Inspector: Komal Charitra

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Inspector notes

Regarding the allegation that staff do not meet residents hygiene needs while in care, according to the reporting party, the residents on the 4 th floor with scabies are not being bathed nor changed. During the investigation, LPA interviewed the Executive Director, Assistant General Manager, Deborah Suarez, and Care Coordination Director, Shirley Cheung and reviewed resident files. According to the Executive Director and staff interviewed, they denied this allegation. Based on the staff interviewed, it was indicated that when the facility received confirmation on 7/21/2023 that R1 tested positive for scabies, all residents and all staff in the memory care unit were treated with the scabies prescription on 7/22/2023. Furthermore, on 7/23/2023, all resident apartments were cleaned, staff provided all memory care unit residents with showers, changed their linens and laundered their personal clothing. Therefore, based on the interviews conducted, and information collected, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred. Report is reviewed with the Executive Director, Sarah Lolayan and a copy is provided.

ComplaintMay 10, 2023· Unsubstantiated
No deficiencies

Inspector: Murial Han

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Inspector notes

According to the building engineer, he/she was notified by the facility via phone on 3/25/2023 that one of the technicians was drilling to install a grab bar in a shower room and accidentally punctured a hold in the main hot water line. The building engineer provided instructions to facility over the phone and contacted the facility's general contractor, CW Dillion right away. The building engineer stated that the contractors arrived at the facility within 30 minutes after the phone call and hot water was restored on the same day and the temperature was measured at 105- 110 degrees F. However, some problems were discovered during the repair which lasted few days but it did not affect the hot water temperature that was also maintained at 105-118 degrees F. In addition, the building engineer stated that prior to the incident, the hot water temperature was automatically set at 116 degrees F but during the repair, it took a little longer for the hot water to reach 116 degrees F but the temperature was always adequate. Furthermore, the building engineer stated that as part of the preventive maintenance program, he/she was performing weekly water temperature checks for the entire building and the hot water temperatures were always within range. Based on the documentation from the outside contractor, they received a call on 3/25/2023 at around 3PM, and hot water was turned on at 5:30PM. They tested the hot water and the temperature was consistent between 105- 110 degrees F. They also noted that the facility was advised that it could take several hours to get above 110 degrees mark as tenants used the hot water. Based on the facility's weekly temperature log during the week of the repair, it revealed the hot water temperature was measured at 112- 120 degrees F. LPA interviewed 5 residents and all of them reported that they were aware of the incident, and the hot water was not as hot as usual but it was not cold as well. In addition, they stated that their daily routine was not interrupted by the incident. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 LPA tested water temperature in 6 apartments on different floors and all the temperature measured at 113- 115.9 degrees F. Based on interviews, record review and observation. this allegation is deemed to be unsubstantiated. Although the above investigations 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. This report is reviewed and discussed with

ComplaintMay 10, 2023· Unsubstantiated
No deficiencies

Inspector: Murial Han

Unsubstantiated — the California Department of Social Services (CDSS) investigated and did not find a violation.

Inspector notes

According to the building engineer, no one has reported the doors were broken and/or a resident was stranded on the rooftop for 45 minutes. In addition, the building engineer explained that if any of the doors were malfunctioned and residents were locked outside, they could talk into their tempo (wrist watch) and request assistance from facility staff. In addition, the building engineer stated that rooftop door was serviced in November, 2022. After the investigation, this allegation is deemed to be unsubstantiated. Regarding to allegation of- resident was not accorded safe, healthful and comfortable accommodations as related to malfunctioned door(s), the reporting party stated that R1 fell multiple times due to the doors. As part of the investigation, LPA interviewed R1 and other residents. According to R1, he/she fell one time on the rooftop while walking the dog. However, he/she slipped but it was not related to the doors. Based on documentation provided, it revealed that R1 slipped and fell once on the rooftop while walking the dogs. LPA interviewed 4 additional residents and all of them reported that they have not encountered the 3rd floor and the rooftop doors being malfunctioned. After the investigation, this allegation is deemed to be unsubstantiated. Although the above investigations 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. This report is reviewed and discussed with the administrator; a copy is provided.

InspectionMay 10, 2023Type A
1 deficiency

Inspector: Murial Han

Inspector notes

On 5/10/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow up on an incident that was reported by the facility. LPA met with administrator, assistant general manager and resident care coordination and explained the purpose of today's visit. On 5/8/2023, LPA was notified by the resident care coordination that early that morning at around 12:30am, facility was notified by a hospital that resident # 1 (R1) was found, and appeared lost resulted the hospital visit. R1 was assessed at the hospital and the facility was informed that R1 was ready to return. According to facility directors, R1 is a resident residing in the memory care unit and during the incident, R1 left the unit from one of the egress exit doors which the alarm should have been triggered as the door opened. However, the alarm did not go off because the alarm was manually turned off by staff. In addition, facility directors stated that since the incident, facility has provided a one on one sitter for R1, in-serviced staff on resident elopement drill & response checklist, purchased additional device for an exit gate to alarm staff when someone leaves. During the case management visit, LPA toured the memory care unit, tested the egress doors and observed them to be adequate. When the alarm went off, staff responded it immediately. Based on interview, facility staff manually turned off the alarm on one the egress doors resulted R1 left the facility unattended. Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with facility director. A copy of this report and the Appeal Rights is provided.

Type ACCR §87468.1(a)(2)

Regulation

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:..(2) To be accorded safe,

Inspector finding

This requirement is not met as evidenced by staff manually turned off the alarm on one of the egress doors in the memory care unit resulted R1 leaving the facility unattended which posed an immediate health risk for resident in care.

Other visitApril 18, 2022
No deficiencies

Inspector: Murial Han

Inspector notes

On 4/18/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the outcome of an incident that the facility reported on 3/29/2022 concerning resident #1(R1) AWOL (Absent Without Official Leave). LPA met with the National Care Director, Jen Johnson and explained the purpose of the visit. During the visit on 3/30/22, LPA interviewed the National Care Director who stated that the concierge at the front desk witnessed R1 leaving the facility and R1's bracelet alarm went off which provided notification to all facility staff that R1 has left the facility unattended. At the same time, staff #1 (S1) was in the lobby and responded to the alarm and followed R1 outside of the facility. Momentarily, staff #2 (S2) also responded to the alarm and went outside looking for R1 and both of them escorted R1 back to the facility safely. R1 did not sustained any injuries due to this incident. LPA interviewed S1 who stated that he/she responded to R1's alarm, and followed R1 out of the facility until S2 arrived and both of them escorted R1 back to the facility. The facility reported that R1 is a new resident and R1 just wanted to take a walk. During the visit on 3/30/22, R1 was not at the facility during LPA's visit, however, the facility reported that upon R1's return, the facility will update R1's care plan to implement safety measures due to this incident. No deficient cited today. This report is reviewed and discussed with the National Care Director. A copy is provided.

Other visitMarch 30, 2022
No deficiencies

Inspector: Murial Han

Inspector notes

On 3/30/2022 Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management inspection regarding to a self reported incident that was reported to CCLD on 3/28/2022. LPA Han met with the National Care Director, Jen Johnson, Care Coordinator Director, Shirley Cheung and the administrator, Sarah Laloyan join the inspection shortly after. On 3/28/2022. the facility reported that concierge witnessed resident #1 (R1) was leaving the facility. R1 was wearing a device that alerted facility staff that he/she has left the facility. Therefore, staff #1 (S1) followed R1 out of the facility and staff #2 (S2) met up with them shortly a few blocks away from the facility and both staff escorted R1 back to the facility safely. Staff stated that there was no injuries noted to R1. During today visit, LPA gathered the following information and documents: Physician report, appraisal needs and services plan, and documentation of resident's check status. LPA also interviewed the concierge on duty, the National Care Director and the Care Coordinator Director. This incident needs further follow-up as LPA requested for additional documents to be submitted to CCL by 4/4/2022 and additional staff interviews. Additional documents requested: - Staff Training Records - Revised LIC 624 (Unusual Incident/Injury Report) - Documentation of the incident This report is reviewed and discussed with administrator. A copy is provided.

Other visitFebruary 23, 2022
No deficiencies

Inspector: Murial Han

Inspector notes

On 2/23/22 at 10:30AM, Licensing Program Analyst (LPA), Murial Han met with the Administrator, Sarah Laloyan to conduct an announced Pre-Licensing inspection. LPA Han was properly screened for COVID-19 at the front entry. LPA observed the indoor and the outdoor passageways are free of obstruction. The Administrator provided a tour of the facility. This is a 14-story level facility with a roof top and excluding a 13th floor. The facility has one bed- room studios and two bed-room apartments. The Memory Care Unit is located on the 4th floor with a total of 33 rooms- 30 single apartments and 3 shared apartments. There is no residents during the inspection. The overall facility is observed to be spacious, cleaned, comfortable temperature and good lighting. The temperature was measure at 70- 76 degrees Fahrenheit (F) and each apartment/studio has a thermostat for the residents to adjust the temperature of their preference. The living rooms, the cinema room, the dinning rooms observed to be comfortable, spacious with adequate furniture. The Activities rooms are equipped with different activities for the residents. The outdoor space is spacious with variety of activities. Emergency exiting plans are posted on every floor. LPA observed COVID-19 signs through-out the facility. There are hand-washing signs posted at each bathroom sink. The water temperature at varies locations- bathrooms, shower rooms, kitchens, etc were measure at 106.2- 118 degrees F. LPA did not observe any toxic, chemicals, disinfectants to be accessible to the residents. There are sufficient lighting in the hallways. LPA observed the elevator permit is current from 12/2/2021- 12/2/2022. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 The facility has a fitness/yoga room for the residents with different exercise equipment and the door is operated by a card key which is a way to notify the facility staff when a resident enters the room so care and supervision can be provided while the resident(s) is using the room. In addition, the fitness/yoga room is equipped with a bathroom/shower room. During the tour, the rooms that LPA observed were cleaned, spacious, good lighting and the temperatures were measured at 70-76 F. There was no bathtubs in any of the rooms but each apartment/studio has a shower room that is equipped with grab bars. The Memory Care Unit entrance is operated by a card key. The environment is calm with comfortable music and lighting. There is a dedicated locked medication room in the unit for medication, resident's records, documentation devices, etc. There is a kitchenette with multiple locked drawers for storage supplies including but not limiting to sharps, plates, cups, etc. The fire extinguisher and the Ansel system were inspected on 12/1/21. LPA observed adequate plates, utensils and cook wares in the kitchen. The facility has a main medication room that is located on the 2nd floor and the set-up is very similar to the medication room on the Memory Care Unit. The facility has a swimming pool that is located on the 11th floor and the entrances are locked/card key controlled. In addition, the door closes automatically after opening and closing. LPA observed the following postings, Resident Rights, Ombudsman Poster, Certification Licensing Complaint Poster, and Theft and Loss Program. LPA observed the PPE supplies are stored on the 7th floor storage room and the staff reported that they are also stored on each floor. Comp III orientation was given to the Administrator, Sarah Laloyan. Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau. Exit interview conducted with the Administrator, Sarah Laloyan and A copy of the report is provided.

ComplaintJanuary 28, 2022
No deficiencies

Inspector: Bethany Hunter

Inspector notes

Facility Type: Residential Care Facility for the Elderly Application Type: Initial Capacity: 260 Census (if any clients in care): 0 COMP II Participants: Sarah Sirun Laloyan Interview Method: Telephone interview On January 28, 2022, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed the understanding of the California Code Title 22 Regulations. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readiness

Federal summary

CMS Care Compare

Not a CMS-certified facility

California RCFEs (residential care facilities for the elderly) are licensed by the state, not by CMS. CMS data only applies to skilled nursing facilities or to CCRCs that operate a licensed SNF wing.

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