Inspection Reports for Coterie Cathedral Hill

The visit was a case management visit concerning a report of suspected abuse received on 2025-09-22 involving a resident who was targeted by an unknown caller requesting a money transfer.

The facility confirmed no calls were made to the resident by staff, and the resident was a victim of an external scam. The facility submitted an incident report to Community Care Licensing and sent a scam prevention notice to all residents. No deficiencies were cited during this visit.

The visit was triggered by a complaint of suspected abuse involving an unknown caller impersonating facility staff and obtaining money from a resident. The complaint was investigated and substantiated as a scam from an outside source, not involving facility staff.

An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with licensing regulations.

The facility was found to be clean, well-maintained, and operating safely with no deficiencies cited. Resident care, staff training, medication management, and safety systems were all in order.

The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff were not meeting resident needs, specifically regarding Activities of Daily Living (ADL) including room checks, continence care, and medication administration assistance for resident R1.

The investigation found that the allegations were unsubstantiated. Evidence showed that ADL tasks were documented as completed, often by an outside private caregiver who dismissed facility staff. Medication administration times were within the facility's allowed one-hour window, and medication records indicated compliance with prescribed instructions.

The complaint alleged that facility staff were not meeting resident R1's needs for ADL and medication administration. The investigation found no preponderance of evidence to prove violations, and the complaint was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 08/30/2024 alleging that facility devices, including elevators and a swimming pool lift, were not properly working.

The investigation found that one of four elevators was not operating on the date of the alleged incident, but three elevators were functioning and accessible. The swimming pool lift was in the process of repair and awaiting parts. Documentation of repair services was provided, and at the time of final inspection, all devices were operating. Due to lack of corroborating evidence, the complaint was found to be unsubstantiated.

Complaint alleges facility devices not properly working including elevator and swimming pool lift. The allegation was found to be unsubstantiated due to contradicting information and lack of corroborating evidence.

An unannounced complaint investigation visit was conducted to address allegations that staff did not do a proper assessment, were charging residents for services not rendered, and were not following the admission agreement.

The investigation found that both residents had signed admission agreements and did not move in due to increased care needs and rates. The facility upheld the 60-day notice rule and charged accordingly. The allegations were determined to be unfounded and the complaint was dismissed.

The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.

The inspection was an unannounced complaint investigation visit conducted due to a complaint received on December 14, 2023, alleging that resident call bells were not answered timely due to lack of staffing.

The investigation found multiple occasions where resident call buttons were not responded to in a timely manner, substantiating the complaint of a violation of residents' personal rights related to timely response to call bells.

The complaint allegation regarding untimely response to resident call bells due to lack of staffing was substantiated based on the preponderance of evidence.

The inspection was an unannounced required 1-year annual inspection conducted to evaluate compliance with licensing requirements.

The facility was found to be in compliance with all regulations, including proper water temperature, safety equipment, food storage, medication management, and staff documentation. No deficiencies were cited during the visit.

An unannounced complaint investigation visit was conducted in response to a complaint received on 07/25/2023 alleging that the licensee does not ensure the facility has sufficient staff to meet the care needs of residents.

The investigation included interviews, document reviews, and observations of the memory care unit. No staff shortages were identified, and the facility scheduling demonstrated adequate staffing to meet residents' needs. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged insufficient staffing to meet resident care needs. The allegation was unsubstantiated after investigation.

The visit was a follow-up regarding an incident report received on September 21, 2023, about a resident who left the facility unattended.

The resident had left the facility with other residents for a community walk with their spouse and returned to notify staff they wished to continue walking without signing in or out. This was not considered abnormal practice. No deficiencies were cited during this visit.

The visit was a case management visit conducted concerning a report of suspected abuse received on 2023-08-07 involving a private duty aide.

No deficiencies were cited during the visit. The private duty aide involved in the abuse allegation was removed from the facility, and the facility has suggested residents hire from preferred agencies.

The visit was triggered by a report of suspected abuse where a resident alleged sexual abuse by a private duty aide. The aide was fingerprinted through the agency and removed from the facility upon the report. Documentation regarding the aide is to be submitted to the Licensing Program Analyst.

An unannounced complaint investigation visit was conducted to investigate an allegation that staff did not comply with infection control practices resulting in a health and safety risk.

The investigation found that infection control plans were in place and being followed, COVID-19 positive residents were isolated, staff were observed using appropriate protective equipment, and notifications to family members were ongoing. The allegation was determined to be unfounded and no citations were issued.

The complaint alleged that staff did not comply with infection control practices resulting in a health and safety risk. The complaint was found to be unfounded, meaning the allegation was false, could not have happened, or was without reasonable basis.

An unannounced complaint investigation visit was conducted in response to allegations that staff did not address a scabies outbreak among residents and did not meet residents' hygiene needs.

The investigation found that the facility did respond appropriately to the scabies outbreak by notifying authorities, treating affected residents and staff, and providing hygiene care. The allegations were determined to be unsubstantiated due to lack of evidence.

The complaint alleged that staff did not address a scabies outbreak and failed to meet residents' hygiene needs. The investigation found no preponderance of evidence to substantiate these allegations.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-28 regarding the facility being without hot water.

The investigation found that a maintenance staff accidentally punctured a hot water pipe causing no hot water for 4 days. The building engineer and contractors repaired the issue promptly, restoring hot water the same day. Water temperature tests and resident interviews confirmed hot water was adequate and daily routines were not interrupted. The allegation was deemed unsubstantiated due to lack of preponderance of evidence.

Complaint was about the facility being without hot water. The allegation was investigated through interviews, water temperature testing, and record review. The complaint was found to be unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations regarding malfunctioning facility doors and unsafe accommodations related to those doors.

The investigation found that the 3rd floor and rooftop doors were functioning properly, and residents interviewed did not report concerns about the doors. The allegations were deemed unsubstantiated due to lack of evidence.

The complaint alleged that facility doors were not in good repair, causing a resident to fall and be locked outside on the rooftop. The investigation included interviews with the resident, other residents, the building engineer, and a facility tour. The resident confirmed a fall unrelated to the doors and denied being locked out. The building engineer reported no prior issues and confirmed recent servicing of the rooftop door. The complaint was unsubstantiated.

The visit was an unannounced case management incident follow-up conducted due to a reported incident where a resident (R1) left the memory care unit unattended after staff manually turned off the alarm on an egress door.

The facility was found deficient for staff manually turning off the alarm on an egress door, which allowed resident R1 to leave the facility unattended, posing an immediate health risk. The facility has since implemented corrective actions including providing a one-on-one sitter, staff in-service on elopement drills, and additional alarm devices.

The visit was triggered by a complaint/incident report regarding resident R1 leaving the memory care unit unattended due to an alarm being manually turned off by staff. The deficiency was substantiated and cited under California Code of Regulations, Title 22, LIC 809D.

The inspection was an unannounced complaint investigation visit conducted to address multiple allegations including failure to follow COVID-19 reporting, masking, testing, quarantining/isolation protocols, and ensuring residents received meals and mail in a timely manner.

The investigation substantiated that the facility failed to report staff COVID-19 positive cases during an outbreak from December 2022 to February 2023, violating reporting requirements. Other allegations regarding masking protocols, resident meal assistance, mail delivery, COVID-19 testing procedures, and isolation protocols were found to be unsubstantiated or unfounded.

The complaint investigation was substantiated regarding failure to follow COVID-19 reporting protocols. The facility did not notify families, Community Care Licensing (CCL), and Local Public Health Department when staff tested positive for COVID-19 as required by Provider Notification Notices. Other allegations related to masking, meal assistance, mail delivery, testing, and isolation protocols were unsubstantiated or unfounded.

The visit was an unannounced case management incident to deliver the outcome of an incident reported on 3/29/2022 concerning resident #1 who was absent without official leave (AWOL).

The facility staff safely escorted the resident back after the resident left the facility unattended. No injuries occurred and no deficiencies were cited during the visit.

An unannounced case management inspection was conducted regarding a self-reported incident where a resident left the facility without injury, reported on 2022-03-28.

The inspection involved gathering documentation and interviews related to the incident. Additional documents and staff interviews were requested for further follow-up.

The visit was an announced Pre-Licensing inspection conducted to evaluate the facility for initial licensure and compliance with regulatory requirements.

The facility was observed to be spacious, clean, well-lit, and comfortable with no residents present during the inspection. Safety measures such as emergency exit plans, locked medication rooms, and controlled access to certain areas were noted. COVID-19 signage and PPE supplies were observed throughout the facility. Immediate licensure is recommended pending final approval.

The visit was an initial licensing evaluation of the Residential Care Facility for the Elderly to assess the applicant's understanding of California Code Title 22 regulations and readiness for licensing.

The applicant/administrator participated in a telephone interview (COMP II) confirming understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Identification was verified and required documentation was obtained.

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