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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540408
Report Date: 08/27/2024
Date Signed: 08/27/2024 03:53:47 PM


Document Has Been Signed on 08/27/2024 03:53 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:JANET'S RESIDENTIAL FACILITY FOR THE ELDERLYFACILITY NUMBER:
380540408
ADMINISTRATOR:SPIRES, JANETFACILITY TYPE:
740
ADDRESS:2970 25TH AVENUETELEPHONE:
(415) 713-8238
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94132
CAPACITY:8CENSUS: 4DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Damien SpiresTIME COMPLETED:
04:00 PM
NARRATIVE
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On 8/27/2024, Licensing Program Analyst(LPA) Dominic Tobola and LPA Yi Sam Jian conducted an unannounced annual inspection. LPAs were greeted by the administrator, Janet Spires(S1) and staff Damien Spires(S2) at 10:10 AM. LPA explained the purpose of the visit. Also present were home care aide Jacqueline Lafleur, staff Karen Lopez, and 4 residents: some with dementia.

LPA Tobola and LPA Jian toured and inspected the physical plant with S2 including but not limited to the kitchen, three bedrooms for residents; one bathroom; laundry area, basement and backyard area.

All outdoor and indoor passageway are free and clear of obstruction. LPA observed sufficient furniture and lighting throughout the facility, and a comfortable temperature of 75 degrees F is maintained. Trash cans were observed to have touch free operated lids. All beds are at least 6" apart from each other. Hot water temperature was measured at 110 degrees Fahrenheit in resident bathroom sink, which is within the required range of 105 to 120 degrees. Auditory alarm required for resident with dementia were not operable during inspection.

No accessible bodies of water or fire safety hazards observed. Fire extinguishers were found to be last serviced and inspected on September 8, 2023. Carbon monoxide detector and smoke detector system were last inspected by outside vendor on 03/2023 in the hallway. 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.

Centrally stored medications are locked in a cabinet near the kitchen entrance in the first floor. Each room is equipped with a bed for each resident working lights and a night stand. Toxins and sharps are stored appropriately and inaccessible to clients. There were sufficient supply of both perishable and nonperishable foods. Food stored in the kitchen refrigerator were properly stored.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
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: JANET'S RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 380540408
VISIT DATE: 08/27/2024
NARRATIVE
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Infection control practices are reviewed: PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap.

During resident file review, LPA found that 3 out of 4 residents needs and services plan and physician reports were in need of updating. LPA found that 2 staffs (S3) (S4) were fingerprint cleared, however not properly associated to the facility. Administrator had submitted request to update facility roaster but pending association. In addition, 2 staffs (S3) (S4) health screen were not on file.

Staff training were also in need of updating, technical violation issued.

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 MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/27/2024 03:53 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: JANET'S RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 380540408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff who are fingerprint cleared but not properly associate to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee agrees to contact Guardian background check bureau and ensure staff (S3 & S4) are associated to the facility by POC date 8/28/2024. Licensee to provide proof of associated staff by POC date 9/3/2024.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, licensee did not comply with the section cited above in all exits requiring auditory alarms not in order, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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Licensee agrees to ensure all auditory alarms are installed and functioning and submit photo proof of evidence to CCLD by POC date 8/28/2024.
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 MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/27/2024 03:53 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: JANET'S RESIDENTIAL FACILITY FOR THE ELDERLY
FACILITY NUMBER: 380540408

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 out 2 staff without health screening reports on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Licensee agrees to submit Health Screening Reports for staff (S3 & S4) by POC date 9/3/2024. In addition, LPA's requested for Licensee to ensure health screening reports are updated for any additional or incoming staff.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 4 needs and service plans and physician's reports in need of updating for residents with dementia, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/10/2024
Plan of Correction
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Licensee agrees to submit updated Needs & Service Plans and Physician's Reports for residents (R1, R2 & R3) by POC date 9/10/2024.
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 MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Yi Sam JianTELEPHONE: 916-268-3959
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4