380504185-9-4-2024-14-AS-YSJN-D8SSU8-20240904141044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504185
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:11:05 PM

Document Has Been Signed on 09/04/2024 02:11 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:	GUIROLA RESIDENT CARE		FACILITY NUMBER:	380504185
ADMINISTRATOR:	GUIROLA, JOSE & TEODORA		FACILITY TYPE:	740
ADDRESS:	618 HOLLOWAY AVENUE		TELEPHONE:	(415) 334-6498
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	6	CENSUS: 4	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Teodora Guirola		TIME COMPLETED:	02:20 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 09/04/2024, Licensing Program Analyst(LPA) Dominic Tobola and LPA Yi Sam Jian conducted an unannounced annual inspection. LPAs were greeted by the administrator Teodora Guirola(S1) at 9:45 AM at the front door as administrator was assisting residents for day program. LPA explained the purpose of the visit and then entered the facility. LPAs began to tour and inspection the physical plant at approximately 10:05am. Also present were staff Jose Guirola(S2) and 3 residents. The physical plant was consistent with the submitted facility sketch/floor plan. The first floor had the garage and other rooms where the Administrator lives. Cleaning solutions and sharps are stored appropriately and inaccessible to clients. The garage stored laundry machines, detergent, canned foods, and two extra refrigerators for clients and staff. Backyard was fenced, secured, and in good condition. All outdoor and indoor passageway were free and clear of obstruction. A comfortable temperature of 69 degrees F was maintained. Hot water temperature were measured at 118 degrees Fahrenheit in 2 resident bathroom sinks, which were within the required range of 105 to 120 degrees. Trash cans were observed to have touch free operated lids. No accessible bodies of water or fire safety hazards observed. Fire extinguishers were adequately charged and in compliance. Carbon monoxide detector and smoke detector system inspected by licensing and met the requirements. Facility has a written emergency disaster plan. Licensee stated there are no firearms or ammunition at the facility. Licensee has at least one completed first aid kit located in the kitchen. The facility has not documented emergency disaster drills within the year. Technical Violation issued. The clients' bedrooms on the second floor were inspected and all had required lighting and furniture. All beds are at least 6" apart from each other. Each room is equipped with a bed for each resident working lights and a nightstand. Continued onto LIC809-C

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam Jian	TELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2024

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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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: GUIROLA RESIDENT CARE	FACILITY NUMBER: 380504185
	VISIT DATE: 09/04/2024

NARRATIVE

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Centrally stored medications are locked in a cabinet near the kitchen entrance in the second floor. There were sufficient supply of both perishable and nonperishable foods. Food stored in the kitchen refrigerator were properly stored. During spot medication check, LPA's found centrally stored medication records to be incomplete with newer medication orders not input.

Based upon a review of staff records, LPA found that all 3 staff, 1st aid & CPR certification were recently expired less than one month prior to inspection date. Licensee will submit updated certification to CCLD. Technical Violation issued. Upon a review of resident records, all 4 residents require an updated needs & service plans. Residents are mostly independent and no major changes of conditions were noted. Technical Violation issued.

Infection control practices are reviewed: PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

This report is reviewed and discussed with the administrator. A copy is provided.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam Jian	TELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/04/2024 02:11 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: GUIROLA RESIDENT CARE	FACILITY NUMBER: 380504185
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(6)

Incidental Medical and Dental Care Services

(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. 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 total of 4 resident's medication not input on centrally stored medication records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/20/2024
	Plan of Correction
1 2 3 4	licensee agrees to ensure all resident's medications are inputed onto the centrally stored medication records. Licensee to provide updated centrally stored medication records to CCLD by POC date 9/20/2024.

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: Yi Sam Jian	TELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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