380540099-8-7-2024-14-AS-DTOA-D7WPC6-20240807111124

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380540099
Report Date: 08/07/2024
Date Signed: 08/07/2024 11:21:41 AM

Document Has Been Signed on 08/07/2024 11:21 AM - 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:	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:	08/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Leonora Aureus, Administrator		TIME COMPLETED:	11:35 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 8/7/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Leonara Aureus. The facility currently provides care for 6 residents, none of which are receiving hospice services or with a diagnosis of dementia. LPA continued with a tour of the facility with Administrator, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/26/2022, however the extinguisher gauge is still within charged meter. LPA spoke with fire inspector and requested for Administrator to immediately contact Fire Department and ensure extinguisher is charged and updated today. Citation issued. Smoke and carbon monoxide detectors found in the primary hallway, were tested and found to be functioning. LPA found that two (2) resident bedrooms did not have smoke alarms installed. However, Administrator provided proof of newly purchased alarms and will have them installed. Administrator to submit photo proof of corrections. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored in locked cabinets in the, bathroom, garage and under kitchen sinks, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Water measured at faucets accessible to residents measured at 116.4 degrees F and within regulation. Residents that were awake during the inspection were observed interacting with staff in the common area, or in their bedroom resting. The facility encourages regular family visits and utilizes outings for resident exercise and mobility. In addition, there is an outdoor patio with shade and large outdoor space for residents. Continued onto LIC809-C

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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: TARAVAL RESIDENTIAL CARE HOME	FACILITY NUMBER: 380540099
	VISIT DATE: 08/07/2024

NARRATIVE

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LPA conducted a sample file review for 3 residents and found all items to be in order. Upon a check of staff files, LPA found that caregiving staff have 1st aid and CPR and annual training up to date. In addition, upon a spot check of medications all medication counts and records are in order.

Leonora Aureus's Administrator Certificate 7005729740 is currently active through 8/14/2024. Administrator has submitted their training requirements for re-certification.

LPA requested the following documents be sent to CCL by COB 8/21/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance

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.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/07/2024 11:21 AM - 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: TARAVAL RESIDENTIAL CARE HOME	FACILITY NUMBER: 380540099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers last inspected in 2022, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	Administrator has contacted the fire inspector and agrees to submit photo proof of correction, updated fire extinguisher charge and inspection to CCLD by POC date 8/8/2024.

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: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC809 (FAS) - (06/04)

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