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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504039
Report Date: 10/09/2024
Date Signed: 10/09/2024 05:19:17 PM


Document Has Been Signed on 10/09/2024 05:19 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
SAN BRUNO RO, 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: 10DATE:
10/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Gloria BalancioTIME COMPLETED:
05:30 PM
NARRATIVE
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On 10/09/2024, Licensing Program Analyst (LPA) Dominic Tabola and LPA Yi Sam Jian conducted an unannounced annual inspection. LPA met with staff members, Franco Balancio and Gloria Balancio. Administrator Ceasar Grepo joined shortly thereafter. LPA explained the purpose of the visit.

The main level had 7 bed rooms for residents, 2 staff rooms, kitchen, dining room, and 3 bathrooms.

Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Medications, toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant, furnishing and lighting was sufficient for comfort and safety.

Carbon monoxide detector and smoke detector system inspected and met the requirements. fire extinguisher checked and fully charged. Licensee has at least one completed first aid kit located in the kitchen.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Upon record reviews and licensee interview, LPA found 1 staff not fingerprint cleared but had been working in facility. Upon review of records, health screening reports for all staff were not on file, residents' admission agreements were not on file , all staffs required updated first aid and CPR training.

Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. No accessible bodies of water or fire safety hazards observed.

Deficiencies of the California Code of Regulations, Title 22 are cited on LIC809-D.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
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 4


Document Has Been Signed on 10/09/2024 05:19 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
SAN BRUNO RO, 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: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review and interview, the licensee did not comply with the section cited above in 1 out of 4 staffs, I(1) not properly assoicated with the facility, licensee indicated that I(1) had been working for a month, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2024
Plan of Correction
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4
Licensee shall submit a written Plan of Correction (POC) describing how Licensee shall request transfer of criminal record clearance for S4, and shall include how Licensee ensure correction and what to do to prevent recurrences of the deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/09/2024 05:19 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
SAN BRUNO RO, 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: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above, 4 out of 4 staffs not having CPR and first aid training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee will provide proof of CPR and first aid training for all staffs by POC due date.
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 4 staffs not having healthscreening reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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LIcensee will submit healthscreening reports for all staff by POC due date.
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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 10/09/2024 05:19 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
SAN BRUNO RO, 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: 10/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(d)
Admisson Agreements
(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 4 out of 5 residents not having admission agreements on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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Licensee will submit completed admission agreements for all residents by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4