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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504039
Report Date: 06/03/2022
Date Signed: 06/03/2022 07:13:16 PM


Document Has Been Signed on 06/03/2022 07:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:LADY OF PERPETUAL HELP RFE #1FACILITY NUMBER:
380504039
ADMINISTRATOR:GREPO, CEASARFACILITY TYPE:
740
ADDRESS:476 FAIR OAKS STREETTELEPHONE:
(415) 648-9533
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY:15CENSUS: 11DATE:
06/03/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:10 PM
MET WITH:Ceasar GrepoTIME COMPLETED:
07:30 PM
NARRATIVE
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During initial complaint visit, LPAs Varilla and Jeung observed deficiencies of the CA Code of Regulations, Title 22, which are cited on a following page.

Upon entry, LPAs were not checked for COVID symptoms nor temperature; there is no visitor log maintained. Residents and staff are also not checked daily for COVID symptoms nor temperature, and there is no log maintained.

Bathrooms are also observed without paper towels, but handwashing reminder signs and liquid soap are available.

Revised facility sketch is requested to be submitted to CCLD, in which room numbers are correctly referenced.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/03/2022 07:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: LADY OF PERPETUAL HELP RFE #1
FACILITY NUMBER: 380504039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2022
Section Cited

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to H & S Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance as specified in Section 87355(c).
This requirement is not met, as evidenced by
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presence of staff M.G., who is not associated to facility, and has been working for 7 days. M.G. has criminal record clearance with RCFE administrator certification. Licensee failed to ensure that staff with client contact has criminal record clearance and assoication with facility, which poses an immediate health, safety or personal rights risk to clients in care.
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Type A
06/06/2022
Section Cited

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STORAGE SPACE
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
Storage areas for poisons...shall be locked.
This requirement was not met, as evidenced by observation of 4 gallon size
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containers of weed killer, flea/tick killer, bed bug killer, "Bug Stop," 3 cans of paint, spray paints on wooden work table in back patio. Also, container of acetone in dining room. Licensee failed to ensure that toxic chemicals are stored where inaccessible to clients, which poses an immediate health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/03/2022 07:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: LADY OF PERPETUAL HELP RFE #1
FACILITY NUMBER: 380504039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2022
Section Cited

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PERSONAL RIGHTS IN ALL FACILITIES Residents in all RCFEs shall have the personal rights to be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met, as procedures for mitigation of COVID are not being followed: Visitors are not screened for COVID and temperature checked upon entry
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and staff and residents are not being screened daily for COVID symptoms and fever.
Licensee failed to ensure that procedures to prevent the spread of COVID infections are being followed according to CCLD Provider Information Notices, which poses a potential health, safety or personal rights risk.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
LIC809 (FAS) - (06/04)
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