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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504039
Report Date: 09/25/2023
Date Signed: 09/25/2023 05:31:48 PM


Document Has Been Signed on 09/25/2023 05:31 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:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Lead Staff, Gloria BalencioTIME COMPLETED:
06:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to conduct an annual/required inspection and met with Lead Staff, Gloria Balencio and explained the reason for the visit. LPA Lund spoke with Administrator Ceasar Grepo who stated that he could not make the visit and gave permission for Lead Staff, Gloria Balencio to sign required paperwork. Census 11 residents, none of which with a diagnosis of dementia and none of which are on hospice.

LPA Lund & Lead Staff, Gloria Balencio toured/inspected facility and grounds was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water or fire safety hazards observed. Rooms have the proper furnishings for residents in care. Fire Extinguishers were found to be last serviced and inspected in 2018. Smoke and Carbon monoxide were tested and functional.

There was sufficient supply of seven day perishable and two day nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins were stored in a secured maintenance closet location in the facility basement. LPA Lund reviewed two staff & three residents files.

Deficiencies observed with Code of Regulations, Title 22, which are cited on a following page.Exit interview conducted with Lead Staff, Gloria Balencio, and copy of report and appeals left.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2023 05:31 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: 09/25/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2023
Plan of Correction
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Administrator Ceasar Grepo will email me a copy of the fire extinguisher company that will service the facility fire extinguishe bye the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Anthony PerezTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason LundTELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
LIC809 (FAS) - (06/04)
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