380540099-8-24-2022-14-AS-MHAN-CHM3FK-20220824181251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380540099
Report Date: 08/24/2022
Date Signed: 08/24/2022 06:13:42 PM

Document Has Been Signed on 08/24/2022 06:13 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:	TARAVAL RESIDENTIAL CARE HOME		FACILITY NUMBER:	380540099
ADMINISTRATOR:	AUREUS, LEONORA		FACILITY TYPE:	740
ADDRESS:	3721 TARAVAL STREET		TELEPHONE:	(415) 681-0294
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94116
CAPACITY:	6	CENSUS: 6	DATE:	08/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Leonora Aureus		TIME COMPLETED:	11:45 AM

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 8/24/22, Licensing Program Analyst(LPA) Murial Han and Co-Worker Kevin Gaines conducted an unannounced annual inspection. LPA observed COVID-19 signs posted through-out the facility. 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- LPA and co-worker's temperatures were taken at the entry, however, it was not observed to be documented. The administrator stated that the daily COVID-19 screening for residents, staff and visitors are completed, however, was not able to provide any documentation. 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 room. 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 and stored in different locations; LPA recommended to store in a common area for easy access. 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, and lighting is sufficient for comfort. First-aid kit is inspected and complete.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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 08/24/2022 06:13 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: TARAVAL RESIDENTIAL CARE HOME	FACILITY NUMBER: 380540099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2022

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
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above as evidenced by the facility was not able to provide documentation on the daily COVID-19 screening for residents, staff and visitors which poses/posed a potential health, safety or personal rights risk to persons in care. This finding was also observed during the inspection on 4/5/2022. Therefore, civil penalty will be assessed today.
	POC Due Date: 08/29/2022
	Plan of Correction
1 2 3 4	The administrator will provide in-services to staff on the importance of documentation of the daily COVID-19 screening result for staff, residents, and visitors. The administrator will start the documentation of such screening today and will submit a copy of the screening result and a copy of the in-service sign-in record to CCL by the plan of correction due day, 8/29/22.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

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: TARAVAL RESIDENTIAL CARE HOME	FACILITY NUMBER: 380540099
	VISIT DATE: 08/24/2022

NARRATIVE

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During today's inspection, LPA and co-worker observed the bathroom is out of service and it is under construction. The administrator stated that the bathroom has piping/plumbing problems and the repair started today. The administrator also stated that it was reported to the resident's responsible parties and their social workers. LPA requested for written plan of the repair to be submitted to CCL by 8/24/22 5pm. The plan shall include but not limited to the scope of work that is being performed, the plan to ensure resident's activities of daily is not interrupted during the repair, when and who were notified, what is the facility's plan to ensure residents are not affected by the repair and the completion date.

During today's inspection, LPA and co-worker observed the fire extinguisher in the kitchen was last inspected on March, 2020 and according to the administrator, this is the only fire extinguisher for the entire facility. Based on observation, deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

During today's inspection, LPA requested a copy of the Affidavit Regarding Client/Resident Cash Resource, and LIC 500 (Personnel Report) by 8/29/2022.

This report is discussed with the administrator. A copy of this report and the Appeal Rights are provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/24/2022 06:13 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: TARAVAL RESIDENTIAL CARE HOME	FACILITY NUMBER: 380540099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87203

This requirement is not met as evidenced by: 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
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above the fire extinguisher in the kitchen was observed to be last inspected on March, 2020. poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/25/2022
	Plan of Correction
1 2 3 4	The facility will have the fire extinguisher inspection completed within 24 hours and submit a copy of proof to CCL by 8/25/22.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC809 (FAS) - (06/04)

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