380504134-6-25-2024-14-AS-JCAA-D6KTC6-20240625143613

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504134
Report Date: 06/25/2024
Date Signed: 06/25/2024 02:36:20 PM

Document Has Been Signed on 06/25/2024 02:36 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:	JULIE'S CARE HOME		FACILITY NUMBER:	380504134
ADMINISTRATOR:	CHAE, JULIE		FACILITY TYPE:	740
ADDRESS:	1363 - 5TH AVENUE		TELEPHONE:	(415) 566-4527
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	14	CENSUS: 8	DATE:	06/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Luzviminda Madraga and Marlon Madraga, Caregivers		TIME COMPLETED:	02:45 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 June 25, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:05 AM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Marlon and Luzviminda Madraga, Caregivers and explained the purpose of the visit. LPA Calandra toured the physical plant. This is a 2-story building with 9 bedrooms, 4 bathrooms, a sun porch, kitchen, dining room, 2 living rooms, pantry, garage, TV room, and backyard. No accessible bodies of water or hazards were observed in the hallways or backyard. The facility had the required furniture and sufficient lighting in all bedrooms. The facility Carbon Monoxide detectors were observed to be in working order. All fire extinguishers were observed to be fully charged but last inspected in 2022. All taps in bathrooms delivered hot water between the required 105-120 degrees Fahrenheit. The facility bathrooms had the required non-skid floor mats and grab bars. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's first aid kit had the required tweezers, bandages, scissors, and other items. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. LPA Calandra reviewed 5 resident records. All were observed to be complete except for 2 residents' files, R1 and R2's files which were missing Annual Needs and Services Plans. LPA Calandra also reviewed 6 staff files. All were observed to be complete. LPA Calandra interviewed 2 residents and 1 staff. 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.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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 06/25/2024 02:36 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: JULIE'S CARE HOME	FACILITY NUMBER: 380504134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	CCR 87309(a) Storage Space: Based on observation, the licensee did not comply with the section cited above in 22 out of 22 detergents and soap which were observed to be unlocked and accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2024
	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.

Type A

Section Cited

CCR

87203

87203: Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	87203: Fire Safety: Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 2 fire extinguishers, which were last inspected on 9/30/2022, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/26/2024
	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.

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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/25/2024 02:36 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: JULIE'S CARE HOME	FACILITY NUMBER: 380504134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/25/2024

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	HSC 1569.695(c): Other Provisions: Based on record review, the licensee did not comply with the section cited above in 1 out of 1 emergency drill documents, which the licensee/administrator could not provide showing the facility's last emergency drill, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/05/2024
	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.

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	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 resident records, which did not have updated/completed Appraisals of residents needs and services for R1 and R2, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/05/2024
	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.

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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: JULIE'S CARE HOME	FACILITY NUMBER: 380504134
	VISIT DATE: 06/25/2024

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LPA Calandra requested the following documents be sent to the Regional Office:
- Proof of Liability Insurance
- Articles of Incorporation
- Administrator Certificate
- updated LIC 500

Sharp objects were observed to be accessible to residents in the kitchen. In the presence of the LPA, Luzviminda Madraga locked up said sharp objects.

A Type A violation was provided for not ensuring that soaps, detergents, and other cleaning supplies were locked and in-accessible to persons in care.

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

A Type B violation was provided for not conducting a quarterly emergency drill and documenting said training.

A Type A violation was provided for not ensuring that fire extinguishers are inspected on an annual basis.

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

An exit interview was conducted. This report was reviewed with Luzviminda Madraga, Caretaker 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: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC809 (FAS) - (06/04)

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