PRINTED: 10/30/2019
FORM APPROVED

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

OMB NO. 0938-0391
(X2) MULTIPLE CONSTRUCTION
A. BUILDING ______________________

(X3) DATE SURVEY
COMPLETED

R-C
555020

B. WING _____________________________

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

375 LAGUNA HONDA BLVD.

LAGUNA HONDA HOSPITAL & REHABILITATION CTR D/P SNF
(X4) ID
PREFIX
TAG

10/15/2019

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

{F 000} INITIAL COMMENTS

SAN FRANCISCO, CA 94116
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETION
DATE

{F 000}

The following reflects the findings of the
California Department of Public Health during a
2nd Re-Visit of an Abbreviated Survey from
10/14/19 to 10/15/19.
Revisit of complaints CA00621775 and
CA00621433 and facility reported incidents
CA00623517, CA00639036, CA00639047,
CA00639051, CA00639848, CA00639918,
CA00639866, CA00640598 and CA00638524.
The inspection was limited to the revisit and does
not represent the findings of a full inspection of
the facility.
Representing the California Department of Public
Health:
Surveyor 33819, Health Facilities Evaluator
Nurse;
Surveyor 40537, Health Facilities Evaluator
Nurse;
Surveyor 40619, Health Facilities Evaluator Nurse

Federal deficiencies F557, F600, F607, F689 and
F755 were corrected.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

(X6) DATE

TITLE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete

Event ID: 8EBF13

Facility ID: CA220000512

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