Inspection Reports for
AlmaVia of San Francisco

The inspection found that two staff members restrained a resident with a gait belt, which posed an immediate health, safety, and personal rights risk. The facility terminated the two staff members and conducted in-service training on restraint risks and reporting requirements. A Type A deficiency was cited for the violation.

The complaint alleged that facility staff did not provide proper notice of rate increase for resident R1. The complaint was substantiated based on review of investigation evidence.

The inspection found inconsistencies in fee amounts charged to resident R1 that did not match the addendum rates or modified conditions stated in the rate increase notices dated 7/31/2020 and 4/30/2021. The facility failed to provide proper notice of rate increases including modified conditions and rate structure changes.

No deficiencies were cited during the visit. An amendment to the original report removed a previously cited deficiency, and no citation was issued.

The complaint alleged that facility staff did not provide proper notice of rate increase for resident (R1). The allegation was substantiated based on evidence including dated notifications, payment ledgers, and invoices showing improper notices and inconsistent fee charges.

The complaint was substantiated as the facility failed to provide proper notice of rate increases on multiple occasions, with inconsistencies found between the notices, ledgers, and invoices regarding fee amounts and rate structures.

The complaint was substantiated. Resident (R1) eloped from the facility on 9/28/2024 during overnight hours due to lack of supervision by staff (S1) who was asleep. R1 has dementia and wandering behavior and is not allowed to leave unassisted.

The complaint was substantiated as it was found that a resident with dementia eloped from the facility during overnight hours because staff was asleep and failed to properly supervise. Deficiencies related to personnel requirements were cited and corrective actions were implemented.

The facility was found to be clean, well-maintained, and compliant with fire safety and food storage regulations. Resident care plans and staff training were mostly up to date, except for one staff member lacking a health screening report. No deficiencies were cited during the visit.

The visit was complaint-related, investigating an incident where resident R1 was injured during transport due to wheelchair lift malfunction and inadequate accommodations. The injury was minor and not due to intent or neglect, but staff did not ensure safe equipment or additional support.

The facility failed to ensure safe accommodations and equipment for resident R1, who sustained a minor injury after falling from a wheelchair lift during transport. The wheelchair lift's manual crank caused a jerking motion contributing to the fall, and the resident's wheelchair type provided less stability.

The complaint was substantiated. The allegation was that staff did not allow residents R1 and R2 to leave the facility. The investigation found that staff incorrectly interpreted the Durable Power of Attorney documents and prevented the residents from leaving, violating residents' rights.

The investigation substantiated the allegation that the facility staff prevented residents R1 and R2 from leaving the facility, violating Title 22 Division 6 Section 87468.1 regarding residents' personal rights to leave the facility at any time. The facility acknowledged the misunderstanding and reported that the residents have since returned home.