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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540099
Report Date: 04/05/2022
Date Signed: 04/05/2022 05:06:34 PM


Document Has Been Signed on 04/05/2022 05:06 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:TARAVAL RESIDENTIAL CARE HOMEFACILITY NUMBER:
380540099
ADMINISTRATOR:AUREUS, LEONORAFACILITY TYPE:
740
ADDRESS:3721 TARAVAL STREETTELEPHONE:
(415) 681-0294
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94116
CAPACITY:6CENSUS: 6DATE:
04/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:administrator, Leonora AureusTIME COMPLETED:
11:45 AM
NARRATIVE
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On 4/5/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA did not observe any COVID-19 signs by the front entrance and LPA was not screened at the point of entry. LPA met with the administrator, Leonora and explained the purpose of the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies (the facility has dedicated a private room for isolation and quarantine). There are 6 residents at the facility (2 female and 4 male residents). There are 4 residents in the living and all of them were wearing face covering. The facility has 3 semi-private rooms and the beds were observed to be 6" apart. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction was not observed. Trash cans in the kitchen are observed to be foot operated.

Medications, and toxins stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During the inspection, the administrator was not able to observe the following: staff, and resident daily screening log, visitor's screening log upon entry, no COVID-19 signs posted in the facility and no hand washing, cough/sneeze etiquette, and physical distancing signs posted with the facility.

Deficiency is observed and cited on a LIC 809Ds. Failure to correct the deficiencies may result in civil penalties.

LPA Han requested for the documents to be submitted to the Regional Office by 4/8/2022:
Emergency Disaster Plan LIC610E, LIC 500, LIC 308, and current administrator certification.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
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 04/05/2022 05:06 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: TARAVAL RESIDENTIAL CARE HOME
FACILITY NUMBER: 380540099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)(5)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (5) Knowledge necessary in order to recognize early signs of illness and the need for professional help.

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 LPA was not screened at the entry point and the administrator was not able to provide any documentation of this process which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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The administrator/designee will develop a plan to ensure all visitors are properly screened for COVID-19 at the point of entry. The administrator will provide education to facility of this process and will submit a copy of the education sign-in record to CCL by 4/19/22. In addition, the administrator will submit a copy of the screening log from 4/5/22 - 4/18/22 to CCL by 4/19/22.
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, record review and interview the licensee did not comply with the section cited above as The administrator was not able to provide any documentation of the routine symptom screening process for residents, and visitors. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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The administrator will ensure all residents, and staff are screened for COVID-19 on a daily basis and the outcome is documented. The administrator will submit a copy of the daily screening log from 4/5/22- 4/18/22 to CCL by 4/19/22.

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: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3


Document Has Been Signed on 04/05/2022 05:06 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: TARAVAL RESIDENTIAL CARE HOME
FACILITY NUMBER: 380540099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87211(a)
Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above as LPA did not observe any COVID-19 infection control signs by the front entrance and through-out the entire facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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The administrator will post COVID-19 signs by the front entrance and around the facility. The administrator will take photos of the signs and submit a copy of the photos to CCL by 4/19/22.
Type B
Section Cited
CCR
87464(f)(1)
Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above as LPA did not observe any hand washing, cough/sneeze etiquette, and physical distancing signs posted with the facility. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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the administrator will post the hand washing, cough/sneeze etiquette, and physical distancing signs in the bathroom(s), and varies locations in the facility. The administrator will take photos of the signs and submit a copy of the photos to CCL by 4/19/22.

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: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3