Inspection Reports for Victorian Manor
1444 McAllister St, San Francisco, CA 94115, United States, CA, 94115
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, and several complaint investigations were unsubstantiated or unfounded, indicating generally good compliance. Some deficiencies were cited in 2023 related to documentation issues, including failure to update and obtain signatures on residents’ Needs and Services Plans, inadequate supervision of a resident with dementia who eloped, and an illegal immediate eviction without proper notice. No fines, license suspensions, or immediate jeopardy findings were reported. The most recent report from December 11, 2024, was free of deficiencies and noted the facility was clean and well-maintained, showing improvement in addressing prior documentation and training concerns. Overall, issues primarily involved resident care documentation and regulatory compliance, with no pattern of severe or repeated violations.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Annual Inspection
Census: 94
Capacity: 124
Deficiencies: 0
Dec 11, 2024
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing requirements and overall care standards.
Findings
The facility was found to be clean, safe, and well-maintained with proper food storage and fire safety measures. Some technical violations were noted regarding outdated medical assessments for dementia residents and incomplete first aid and CPR training for staff, but no deficiencies were cited.
Report Facts
Residents: 94
Capacity: 124
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Pacheco | Administrator | Named in relation to facility administration and certification |
| Bernadette Joseph | Licensee | Greeted Licensing Program Analyst during inspection |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and authored the report |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 124
Deficiencies: 0
Feb 14, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received regarding medication mismanagement, refusal to provide menus to a resident's authorized representative, and failure to meet resident's needs.
Findings
The investigation found that the resident had frequent hospitalizations and medication changes, which impacted the facility's ability to meet needs. Medication administration records showed the resident did receive the questioned medication, and menus were posted weekly. The facility follows physician dietary recommendations but does not have a dietician on staff. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included medication mismanagement, refusal to provide menus, and unmet resident needs. Evidence did not support the allegations.
Report Facts
Capacity: 124
Census: 83
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation |
| Ana Pacheco | Administrator | Facility administrator met during investigation |
| April Cowan | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 124
Deficiencies: 0
Dec 27, 2023
Visit Reason
Unannounced investigation of a complaint received on 2023-12-05 regarding resident injuries and failure to report injuries to responsible party.
Findings
Investigation found skin discoloration on resident's leg was observed but not documented by hospice nurse. Facility assessment could not confirm discoloration. Allegations were determined to be unfounded, meaning they could not have happened or lacked reasonable basis.
Complaint Details
Complaint involved allegations that a resident sustained injuries in care and the facility failed to report injuries to the responsible party. The complaint was determined to be unfounded.
Report Facts
Complaint control number: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Audrey Jeung | Evaluator | Conducted the complaint investigation |
| Ana Pacheco | Administrator | Facility administrator met during investigation |
| Cara Smith | Licensing Program Manager | Named in report signature section |
Inspection Report
Follow-Up
Census: 84
Capacity: 124
Deficiencies: 1
Dec 11, 2023
Visit Reason
This visit was a follow-up to a case management visit on 10/2/2023 to discuss citations issued on that day and subsequent communications regarding client #1.
Findings
The facility was cited for failing to ensure that the Needs and Services Plan for client #1 was signed and acknowledged by the client or their responsible party, posing a potential health, safety, or personal rights risk.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure that the written Needs and Services Plan was acknowledged and signed by the resident or their representative, which posed a potential health, safety, or personal rights risk. | Type B |
Report Facts
Capacity: 124
Census: 84
Plan of Correction Due Date: Dec 18, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Pacheco | Administrator | Met with licensing analyst to discuss citations and appeals |
| Audrey Jeung | Licensing Program Analyst | Conducted the follow-up visit and signed the report |
| Cara Smith | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 124
Deficiencies: 2
Oct 2, 2023
Visit Reason
The visit was conducted in response to an Incident Report dated 08/02/2023 regarding client #1, to review submitted documentation including a Physician's Report and Needs and Services Plan.
Findings
Deficiencies were cited related to care of persons with dementia, including inadequate supervision leading to a client eloping from the facility and failure to ensure annual medical assessments and reappraisals addressing dementia care needs. The medical report was over two years old and did not adequately address wandering behavior.
Complaint Details
Visit was complaint-related, triggered by an Incident Report dated 08/02/2023. Substantiation status is not explicitly stated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff did not adequately supervise client on 8/3/23 when he eloped from facility, failing to ensure client safety and posing a potential health, safety, or personal rights risk. | Type B |
| Failure to ensure each resident with dementia had an annual medical assessment and reappraisal including reassessment of dementia care needs; medical report was over 2 years old and appraisal did not adequately address wandering behavior. | Type B |
Report Facts
Capacity: 124
Census: 84
Plan of Correction Due Date: Oct 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cara Smith | Licensing Program Manager | Named as supervisor and licensing program manager |
| Audrey Jeung | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 124
Deficiencies: 1
Sep 8, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations including illegal eviction of a resident and retaliation against a resident for making complaints.
Findings
The investigation substantiated that the facility issued an immediate eviction notice to a resident without providing the required 30-day written notice, violating Title 22 regulations. The allegation of retaliation against the resident for making complaints was found to be unfounded.
Complaint Details
The complaint investigation was substantiated for illegal eviction due to failure to provide a 30-day notice as required by regulation. The retaliation allegation was found to be unfounded.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee gave an immediate eviction notice to a resident without providing the required 30-day written notice as required by CCR 87224(a). | Type A |
Report Facts
Capacity: 124
Census: 84
Deficiencies cited: 1
Plan of Correction Due Date: Sep 9, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jackie Jin | Licensing Program Manager | Named in relation to deficiency citation and report oversight |
| Ana Pacheco | Administrator | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 124
Deficiencies: 3
Jul 5, 2023
Visit Reason
An unannounced case management visit was conducted to deliver findings related to complaint #14-AS-20230616164015 concerning a resident's hospital transfer and related reporting and care plan deficiencies.
Findings
The investigation found that resident #1 was transferred to the hospital on 6/5/2023 but the incident was not reported to the licensing agency. Additionally, the resident's needs and services plan was not updated timely, was unsigned by the resident and responsible parties, and the resident was unaware of the care planning process. Deficiencies were cited under California Code of Regulations, Title 22.
Complaint Details
Complaint #14-AS-20230616164015 regarding failure to report a hospital transfer and deficiencies in updating and signing the resident's needs and services plan.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident #1 had a change in health condition and the needs and services plan was not updated in a timely fashion, posing potential health risks. | Type B |
| Resident #1's needs and services plan was updated but the signature page was blank, indicating lack of resident review and participation. | Type B |
| Resident #1's hospital transfer on 6/5/2023 was not reported to the Community Care Licensing Division as required. | Type B |
Report Facts
Deficiencies cited: 3
Plan of Correction Due Date: Jul 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Supervisor overseeing the investigation |
| Ana Pacheco | Administrator | Facility administrator involved in the findings discussion |
| Louie Bautista | Care Coordinator | Met with Licensing Program Analyst during the visit |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 124
Deficiencies: 1
Jul 5, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-06-16 regarding staff handling residents roughly, inadequate feeding, and serving cold food to a resident.
Findings
The investigation found no preponderance of evidence to substantiate the allegations of rough handling, inadequate feeding, or serving cold food. The administrator had addressed concerns with the resident, and staff and other residents reported respectful care. However, the facility failed to update the resident's needs and services plan to reflect current health conditions, which will be cited under Case Management.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff handling a resident roughly, not ensuring adequate feeding, and serving cold food. Interviews with the resident, staff, administrator, other residents, and family members did not support the allegations. The administrator had met with the resident and developed a plan to improve communication during care. The facility staff assisted with feeding and warmed food upon request. The only deficiency found was the failure to update the resident's care plan timely.
Deficiencies (1)
| Description |
|---|
| Failure to update resident's needs and services plan to reflect current health condition |
Report Facts
Capacity: 124
Census: 84
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Ana Pacheco | Administrator | Facility administrator involved in investigation and interviews |
| Louie Bautista | Care Coordinator | Met with Licensing Program Analyst during investigation |
| Cara Smith | Licensing Program Manager | Oversaw complaint investigation report |
Inspection Report
Annual Inspection
Census: 75
Capacity: 124
Deficiencies: 0
Jan 27, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control practices.
Findings
The inspection found no deficiencies. COVID-19 signage and infection control measures were observed, medications and sharps were stored properly, and environmental conditions were adequate.
Report Facts
Capacity: 124
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Pacheco | Administrator | Met with Licensing Program Analyst during inspection |
| Murial Han | Licensing Program Analyst | Conducted the inspection |
| Cara Smith | Licensing Program Manager | Named in report header |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 124
Deficiencies: 0
Jan 27, 2023
Visit Reason
Unannounced complaint investigation visit conducted in response to multiple allegations including improper staff response to a resident being burned, unmet toileting needs, inadequate staffing, medication administration issues, staff retaliation, and resident respect concerns.
Findings
All allegations were investigated through interviews, record reviews, and observations. The allegation of a resident being burned was unsubstantiated due to lack of evidence. Allegations regarding toileting needs and staffing were also unsubstantiated. Medication administration, staff retaliation, failure to prevent another resident entering a room, and disrespectful treatment allegations were all found to be unfounded.
Complaint Details
The complaint investigation was triggered by allegations received on 09/26/2022. The investigation found the allegations of improper staff response to a burn incident, unmet toileting needs, inadequate staffing, medication administration errors, staff retaliation, failure to prevent another resident entering a resident's room, and disrespectful treatment to be unsubstantiated or unfounded based on interviews, observations, and record reviews.
Report Facts
Capacity: 124
Census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Pacheco | Administrator | Met with Licensing Program Analyst during investigation and provided statements denying allegations |
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Follow-Up
Census: 75
Capacity: 124
Deficiencies: 0
Aug 10, 2022
Visit Reason
The visit was an unannounced health and welfare check conducted as a follow-up to a previous health and welfare check on 2022-07-12 concerning three residents admitted from a skilled nursing facility.
Findings
During the visit, the Licensing Program Analyst met with the three residents who reported doing well, and no deficiencies were cited.
Report Facts
Residents admitted from skilled nursing facility: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced health and welfare check and met with the administrator and residents |
| Ana Pacheco | Administrator | Facility administrator met with the Licensing Program Analyst during the visit |
| Jackie Jin | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Census: 74
Capacity: 124
Deficiencies: 0
Jul 12, 2022
Visit Reason
An unannounced Health and Welfare check was conducted because the facility admitted 3 residents from a skilled nursing facility and is anticipating admitting additional residents from the same facility.
Findings
No deficiencies were found during the visit. The Licensing Program Analyst reviewed various resident and facility documents and interviewed the 3 residents, who reported receiving needed care but needing time to adjust to the new environment.
Report Facts
Residents admitted from skilled nursing facility: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Pacheco | Administrator | Met with Licensing Program Analyst during the visit and provided information about admissions and staffing |
| Murial Han | Licensing Program Analyst | Conducted the unannounced Health and Welfare check |
| Julio Montes | Licensing Program Manager | Named in the report header |
Inspection Report
Annual Inspection
Census: 71
Capacity: 124
Deficiencies: 0
Dec 2, 2021
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control practices.
Findings
No deficiencies were cited during the inspection. The facility demonstrated adequate infection control measures, proper storage of medications and sharps, and maintained a comfortable environment. Some documents were requested for submission to the Regional Office.
Report Facts
Capacity: 124
Census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ana Pacheco | Administrator | Met with Licensing Program Analyst during inspection and discussed report findings |
| Murial Han | Licensing Program Analyst | Conducted the inspection |
| Julio Montes | Licensing Program Manager | Named in report as Licensing Program Manager |
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