380504099-7-31-2024-14-AS-JCAA-D7PUHW-20240731153638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504099
Report Date: 07/31/2024
Date Signed: 07/31/2024 03:38:07 PM

Document Has Been Signed on 07/31/2024 03:38 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:	KIMOCHI HOME		FACILITY NUMBER:	380504099
ADMINISTRATOR:	CHAN, LINDA ISHII		FACILITY TYPE:	740
ADDRESS:	1531 SUTTER STREET		TELEPHONE:	(415) 922-9972
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	20	CENSUS: 13	DATE:	07/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Linda Ishii, Administrator		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 31, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:40 AM to complete the Annual 1-year required inspection. LPA Calandra was greeted by Sandy Ishii, Adult Day Care Program Coordinator and explained the purpose of the visit. Linda Ishii, Administrator arrived later during the visit. LPA Calandra toured the physical plant. This is a 2-story building with 14 bedrooms, 4 bathrooms, a kitchen, dining room, lounge, garden, foyer, staff offices, and recreation room. All bedrooms had the required furniture and sufficient lighting. The facility's thermostat was set at a comfortable temperature of 72.5 degrees Fahrenheit. Hot water temperature was measured at 114.8 degrees Fahrenheit within the required range. The facility had the required 7 days of non-perishables and 2 days of perishables on hand. No food was expired. The facility's fire extinguishers were last inspected on January 28, 2024 and all were observed to be fully charged. The facility's smoke detectors and carbon monoxide detectors were observed to be in working order. All soaps, detergents, and poisons were observed to be locked and in-accessible to persons in care. Knives, and other sharp objects were accessible to persons in care but locked in the presence of the LPA. This facility does not handle cash resources for clients. LPA Calandra reviewed Centrally Stored Medications Records(CSMR). A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. LPA Calandra reviewed 5 client records and 5 staff records. All client records were observed to be missing the Annual Needs and Services Plan. All staff files were observed to be complete.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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 3

Document Has Been Signed on 07/31/2024 03:38 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: KIMOCHI HOME	FACILITY NUMBER: 380504099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	HSC 1569.695(e)(2): Other Provisions: Based on record review, the licensee did not comply with the section cited above in 5 out of 13 resident records, which were missing the Appraisal of resident needs and services plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/14/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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 Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: KIMOCHI HOME	FACILITY NUMBER: 380504099
	VISIT DATE: 07/31/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

A Type B violation was provided for not having Annual Needs and Services Plans for R1, R2, R3, R4, and R5.

A Technical violation was also provided for not ensuring Appraisals are conducted for Dementia patients on an ongoing basis.

LPA Calandra requested the following documents be sent to the Department:

-Current Liability Insurance
-Transportation Procedures

Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted. This report was reviewed with Linda Ishii, Administrator and a copy of the report left at the facility along with Appeal rights.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3