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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540303
Report Date: 11/18/2022
Date Signed: 11/18/2022 04:24:48 PM

Document Has Been Signed on 11/18/2022 04:24 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
Lookup Error,
, CA
FACILITY NAME:RUSTAN ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
380540303
ADMINISTRATOR:RUIZ, NECITA IFACILITY TYPE:
735
ADDRESS:460 UTAH STREETTELEPHONE:
(916) 690-0728
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94110
CAPACITY: 6CENSUS: 10DATE:
11/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Leah RuizTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Walters arrived unannounced to conduct a Annual Required - 1 Year inspection and was granted entry into the facility by staff. The Administrator Leah Ruiz arrived later. This adult residential care facility is licensed for 6 clients, however there were 10 clients currently residing in the facility. There were 3 staff present at the time. 1 of the 2 licensees has passed away. LPA advised Administrator to contact San Bruno Regional Office and provide them with copy of the death certificate.

At the entrance of the facility LPA observed hand sanitizer for visitors and signs posted outside to promote droplet precautions. There were additional signs with to screen visitors for COVID symptoms. Facility had at least a 30 day supply of personal protective equipment.

LPA then toured the facility with staff and made the following observations: LPA observed rodent droppings on the linen in the linen closet.(pictures taken) LPA and staff proceeded to tour the home, LPA and staff then observed a rodent pass them and under the oven within the kitchen. Bathrooms had hand washing supplies.

Client bedrooms were furnished as required per regulation. LPA observed locks on all of the clients bedroom closets. (pictures taken) Clients did not have access to keys to be able to access their clothing items. Facility did not have have a behavioral plan that indicates that they're approved to lock the client doors.

Continued on 809 C
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2022
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 11/18/2022 04:24 PM - It Cannot Be Edited


Created By: Katrina Walters On 11/18/2022 at 03:12 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: RUSTAN ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 380540303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited

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85072(b) The licensee shall insure that each client is accorded the following personal rights.(6) To possess and use his/her own personal items,..
This requirement has not been met as evidence by:
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Based on LPAs observation Licensee did not ensure clients personal rights were maintained when clients did not have access to their clothing items. This poses an immediate risk to the health, safety and personal rights to the residents in care.
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Type A
11/21/2022
Section Cited

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(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Based on LPA observation of cleaning products, medications, mouthwash and sharps the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2022 04:24 PM - It Cannot Be Edited


Created By: Katrina Walters On 11/18/2022 at 03:33 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: RUSTAN ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 380540303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited

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80010(a) Limitations. Capacity and Ambulatory Status - A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including the maximum number of persons who may receive services at any one time.
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Based on LPA's observation and interviews the facility was over capacity by 4 additional clients. Which poses an immediate health and safety risk to clients in care.
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Type A
11/21/2022
Section Cited

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80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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Based on LPA's observation, the licensee did not comply when they blocked an exit and removed all smoke and carbon monoxide detectors which poses an immediate health and safety risk.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/18/2022 04:24 PM - It Cannot Be Edited


Created By: Katrina Walters On 11/18/2022 at 03:44 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
,
, CA

FACILITY NAME: RUSTAN ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 380540303

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/21/2022
Section Cited

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(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
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Based on LPA's observation during inspection rodents droppings in the hallway closet and rodents moving throughout the faciltiy which poses an immediate risk to the health & safety of residents in care.
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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:Hope DeBenedetti
LICENSING EVALUATOR NAME:Katrina Walters
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022


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Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: RUSTAN ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 380540303
VISIT DATE: 11/18/2022
NARRATIVE
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LPA continued to tour the facility and observed that clients watching tv in large room in a portion of the home that has not been licensed by community care licensing. In that area there two beds: 1 bed for client and 1 bed for staff. Additionally there were two matts on the floor, that staff confirmed that were for clients. (pictures taken) Another client was in a bedroom, that was not licensed or approved by the fire department. In the large room that clients were sleeping in, there were bottles of alcohol that were accessible to clients in care.(pictures taken) LPA also observed that clients had access to other items that could be considered a hazard to clients such as medication, mouthwash and sharp objects.

LPA observed that an exit was blocked with boxes. Boxes and other items were surrounding the hot water heater. Items were stacked more than 5 ft tall. Smoke and carbon monoxide detectors had been taken off of the walls. (pictures taken). Staff stated that they removed the smoke detectors because the clients behavioral concerns. Staff immediately placed the smoke detector and carbon monoxide detector back onto the wall.

Deficiencies were observed and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Civil penalty assessed during todays Required 1-year inspection for the amount of $500. Appeal rights given to the Administrator. A copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Katrina Walters
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2022
LIC809 (FAS) - (06/04)
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