Inspection visit

ComplaintOctober 20, 2022

SUTRO HEIGHTS CORPORATIONLicense 3856010972 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

Regarding to the allegation of staff do not treat resident with dignity and respect, in addition to staff yelled at R1, R1 stated that when R1 was hospitalized, facility staff moved R1's belongings without R1's presence and permission. As part of the investigation, LPA interviewed S1 who acknowledged that staff moved and cleaned R1's belongings while R1 was out of the facility as R1's room was too cluttered. During LPA's 10-day complaint inspection, LPA observed R1's personal belongings were displaced from R1's room without R1's consent. After the investigation, this allegation is substantiated. Based on interviews and observations during the course of the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. This report is discussed with Administrator and a copy of is provided including the Appeal Rights. During the 10-day complaint visit, LPA observed R1 was lying on a hospital bed with a special pressure relieving mattress, and 2 half bedrails up by the head of the hospital bed. Based on the documents provided, LPA observed the dates and times when R1 refused to be turned and repositioned by staff. Base on record review, observations, and interviews during the course of investigation, this allegation is unsubstantiated as the facility provided actions to prevent R1 from developing pressure injuries including making referral to a home health agency for wound management and obtaining a special mattress for relieving pressure but due to R1's health condition, R1 developed pressure ulcer and it was healed. Although the above allegation is deemed to be unsubstantiated, the facility was not able to provide a written order from the physician for the half bedrails, therefore, this finding will be cited on a LIC 809 and LIC809D under Postural Supports. Regarding to resident developed a rash while in care, the reporting party stated that R1 developed a rash due to the plastic ties from the adult brief were too tight around R1's stomach. As part of the investigation, LPA interviewed R1 who did not express any concerns regarding to staff placing the adult brief too tight and R1 was not aware of a rash developed around R1's stomach. LPA interviewed staff who stated that they knew not to place the audit brief too tight on R1 and they left one plastic tie untied. LPA observed R1 and validated this practice. Based on interviews and observations during the course of the investigation, this allegation is deemed to be unsubstantiated. Regarding to resident is not properly bathed while in care, the reporting party stated that facility staff often do not rinse the soap off of R1 thoroughly after a bed bath. As part of the investigation, LPA interviewed the former facility manager who denied the allegation and stated that facility has recently switched from regular soap to a no-rinse bathing wipes for bed baths. Therefore, there was no rinse-off needed and it would be normal for a resident to feel the mild cleaning solution that is contained on the wipes after the bed bath. LPA interviewed R1 who stated that the facility staff was providing unsatisfactory bed baths as staff did not rinse R1 thoroughly as R1 continued to have the slippery sensation on the skin after the bed baths. LPA interviewed resident #2 (R2) and resident #3 (R3) who also received bed baths from staff and both of them reported that they were satisfied with the bed baths that they were provided. Based on interviews and observations, this allegation is deemed to be unsubstantiated. Facility staff has explained to R1 of the no-rinse bathing wipes and agreed to go back to soap if R1 prefers. 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 discussed and reviewed with the administrator. A copy is provided.

Citations

9 citations recorded^*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

1569.652(c)Type B
§1569.652 Termination of admission agreement upon death of resident;...(c) A refund of any fees paid in advance....within 15 days after the personal property is removed. This requirement is not met as evidence by: In January 2022, R1 stayed at the facility for a few days and the responsible party paid for the entire month but the facility has yet refunded the unused portion of the payment to the RP poses a potential risk to person(s) in care.
87507(e)Type B
Provide copies of signed agreements and amendments
87507 Admission Agreements..(e) The licensee shall provide a copy of the signed and dated current admission agreement,..to the resident or the resident's representative, The requirment is not met as evidenced by: The facility did not provide a copy R1's admission agreement to R1's responsible party despite R1's responsible party's requests which poses a potential risk to person(s) in care.
87413(a)(2)Type A
87413 Personnel - Operations (a) In each facility:(2) Care and supervision of residents shall be provided without physical or verbal abuse, exploitation or prejudice. The requirement is not met as evidenced by: staff #1 (S1) yelled at residents during care and supervision which poses an immediate health risks to residents in care.
87468.2(a)(1)Type B
Right to personal privacy in daily care
87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...(1) To have a reasonable level of personal privacy in accommodations... This requirement is not met as evidenced by: The facility moved and displaced resident #1's personal belongings from R1's room without R1's presence, and consent which poses a potential health risks for resident in care.
1569.80(a)Type A
§1569.80 Care and services decision making; meeting; written record a) A resident of a residential care facility for the elderly, or the resident's representative, or both, shall have the right to participate in decision making regarding the care and services to be provided to the resident. This requirement is not met as evidenced by: R1 is satisfied with services that was provided by the home health visiting nurse. However the facility pressured R1 discontinuing the services from this visting nurse which posed an immediately health risks to resident in care.
87457(c)(3)Type B
87457 Pre-Admission Appraisal - General(c)Prior to admission a determination of the prospective resident's suitability for admission shall be completed..(3) The prospective resident, or his/her responsible person,...shall be involved in the development of the appraisal. This requirement is not met as evidenced by R1 and R2's appraisal needs/service plans were not signed indicating it's reviewed and agreed by the residents and/or their responsible parties which poses a potential health risk to residents in care.
87463(a)Type B
Update reappraisal at required intervals
87463 Reappraisals(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. This requirement is not met as evidenced by: during the 10-day initial complaint visit, LPA observed R1 and R2 have half bed rails up by the head of their beds, however, the need of utilzing this device was not reflected in their appraisal needs which poses a potential health risk to residents in care
87608(a)(3)Type B
Maintain physician order documentation in resident record
87608 Postural Supports (a) Based on the individual's preadmission appraisal, Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support... This requirement is not met as evidence by: R1 and R2 have half bed rails by the head of the bed and there was no written order from their physician which poses a potential health risks to residents in care.
87506(a)(b)(15)Type B
87506 Resident Records(a)The licensee shall ensure...a current record is maintained for each resident in the facility.. readily available to facility staff and to licensing agency staff..(b) Each resident’s record shall contain.. (15)The admission agreement..This requirement is not met as evidenced by: the facility did not have resident #1 (R1)'s admission agreement in the facility which poses a potential health risk to residents in care.

FAQ · About this visit

Common questions about this visit

What happened during the October 20, 2022 inspection of SUTRO HEIGHTS CORPORATION?

This was a complaint inspection of SUTRO HEIGHTS CORPORATION on October 20, 2022. 2 citations were issued: 1 Type A (serious) and 1 Type B.

Were any citations issued to SUTRO HEIGHTS CORPORATION on October 20, 2022?

Yes, 2 citations were issued (1 Type A, 1 Type B). The first citation was for: "§1569.652 Termination of admission agreement upon death of resident;...(c) A refund of any fees paid in advance....withi..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated June 15, 2026. If you believe any information is inaccurate, report it here.

Complaint·October 20, 2022