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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380504134
Report Date: 06/13/2022
Date Signed: 06/13/2022 09:22:10 PM


Document Has Been Signed on 06/13/2022 09:22 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:JULIE'S CARE HOMEFACILITY NUMBER:
380504134
ADMINISTRATOR:CHAE, JULIEFACILITY TYPE:
740
ADDRESS:1363 - 5TH AVENUETELEPHONE:
(415) 566-4527
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY:14CENSUS: 11DATE:
06/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Caregiver, Luzviminda Madraga.TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual required inspection. LPA was greeted by caregiver, Luzviminda Madraga and explained the purpose of the visit.

LPA was screened by staff. LPA reviewed the daily visitor, staff and resident screening logs and observed the logs are not being completed on a daily basis. Based on the visitor's COVID-19 screening logs, there were some visitors who signed in and out on the sign-in and out logs but they were not screened. In addition, based on the daily staff and resident's COVID-19 screening logs, there were missing documentation from April and May, 2022. LPA discussed this finding with facility staff who acknowledged that there were missing documentation.

LPA proceed with the tour of the facility provided by caregiver beginning in the 2nd floor dining room and observed 1 long table against the wall and chairs. The kitchen observed to be neat, and tidy. COVID-19 Infection Control signs are posted in the 1st and the 2nd floor dining rooms. Hand washing stations were equipped with paper supplies, liquid soap and hand-washing signs posted. LPA observed adequate PPE supplies. .

The facility has an indoor and outdoor designated visitation area. Trash bins were observed to have closed lids. The bed rooms were observed to be furnished per Title 22 regulations. Beds were spaced at least 6 feet apart. Food supply was checked and observed to be sufficient. The medication storage was locked and inaccessible to residents. First aid kit was sufficient.

Deficiencies of the RCFE California Code of Regulations, Title 22 is cited on LIC809D Failure to correct the deficiencies may result in civil penalties.

During today's visit, the assistant administrator was present during partial of the inspection as he/she had to leave and assist a resident with a medical appointment. Therefore, This report is reviewed, discussed with caregiver, Luz Magdraga.

A copy of this report is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
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 06/13/2022 09:22 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: JULIE'S CARE HOME
FACILITY NUMBER: 380504134

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as evidenced by LPA observed the daily visitor, resident and staff COVID-19 logs were incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/27/2022
Plan of Correction
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The facility will provide a plan to CCL by 6/27/2022 to ensure visitors, residents and staff are screened on a daily basis and the screening result is documented accordingly. The facilty will provide of copy of the screening documenation to CCL from 6/14/2022 to 6/27/2022 to ensure it is completed.
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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2022
LIC809 (FAS) - (06/04)
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