380504099-6-13-2023-14-AS-MHAN-CSS2AP-20230613171348

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504099
Report Date: 06/13/2023
Date Signed: 06/13/2023 05:15:00 PM

Document Has Been Signed on 06/13/2023 05:15 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
SF COASTAL AC/SC, 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: 14	DATE:	06/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator, Linda Ishii Chan		TIME COMPLETED:	02:30 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 6/13/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator and explained the purpose of the visit. Administrator provided a tour of the facility and LPA observed the facility to be cleaned, tidy and in good repair. On the ground level, there are common areas, kitchen, offices, medication room, living room, activity room and 2 bathrooms. On the 2nd floor, there are 14 bed rooms (some shared and some privates), 2 shower/bathrooms, 1 bathroom, electrical room, supply storage room, etc. Bedrooms were equipped with the required furniture for residents to use. Bathrooms/shower rooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 106- 112 degrees F. Facility is equipped with smoke (in every room) and carbon monoxide detectors. Fire extinguishers were last serviced on 1/23/2023, and 1/17/2023. During the facility tour, LPA observed the kitchen door was open with no staff present and the sharps cabinets were not locked. LPA observed medication cabinets were locked and inaccessible to residents. LPA conducted staff and resident interviews and file reviews.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KIMOCHI HOME	FACILITY NUMBER: 380504099
	VISIT DATE: 06/13/2023

NARRATIVE

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4 resident records were reviewed and observed to have medical assessments signed by a medical professional, completed pre-admission appraisals, completed admission agreements , and LIC602 reports.

3 staff files were reviewed and appeared complete.

Staff members at the facility were fingerprint cleared and associated to the facility.

Centrally stored medication process were reviewed.

In reviewing facility disaster process, LPA observed facility failed to complete the fire/emergency drills as required.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed. A copy of this report and Appeal Rights will be provided due to technically difficulties.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 06/13/2023 05:15 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KIMOCHI HOME	FACILITY NUMBER: 380504099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, observation and record review the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will conduct a fire/emergency drill with each staff on each shift and submit a copy of the staff sign-in sheet to CCL by 6/20/2023. In addition, the administrator/licensee will develop a plan to ensure compliance.

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff training. The administrator/licensee will provide a photo(s) to CCL to proof that the sharps are locked and inaccessible to residents in care.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2023

LIC809 (FAS) - (06/04)

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