385600019-8-8-2024-14-AS-DTOA-D7XQVU-20240808123056

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600019
Report Date: 08/08/2024
Date Signed: 08/08/2024 12:31:45 PM

Document Has Been Signed on 08/08/2024 12:31 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:	PROVIDENCE PLACE		FACILITY NUMBER:	385600019
ADMINISTRATOR:	KNOP, GALINA		FACILITY TYPE:	740
ADDRESS:	2456 GEARY BLVD.		TELEPHONE:	(415) 359-9700
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94115
CAPACITY:	34	CENSUS: 34	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Catherine Villegas, Wellness Director		TIME COMPLETED:	12:45 PM

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 8/8/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver Staff, Joy Bautista. Wellness Director, Catherine Villegas was contacted and arrived later in the visit. The facility currently provides care for 34 residents, 2 of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, 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 Extinguishers located on each floor were found to be last charged on 6/6/2024. Smoke and carbon monoxide detectors are interconnected. Fire Safety Inspection was completed on 7/23/2024 indicating all fire safety devices and systems to be in order. 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, sufficient for residents in care. Facility allows residents to choose meals on various preferences while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, 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. Residents that were awake during the inspection were observed interacting with staff in the common areas, or in their bedroom resting. In addition, there is large outdoor backyard space for resident use. The facility encourages regular family visits and utilizes a wide variety of activities. The Activities Director and caregiver staff were observed engaging continuously with residents, offering activities based on individualized preferences and abilities. LPA found that the engagement is very well practiced with activity calendars developed on a monthly. Residents were observed to have a positive relationship with staff. 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: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

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: PROVIDENCE PLACE	FACILITY NUMBER: 385600019
	VISIT DATE: 08/08/2024

NARRATIVE

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LPA conducted a sample file review for 10 residents and found three (3) residents requiring Needs & Service Plans updated. Upon a check of spot check of seven (7) staff files, LPA found that caregiving staff have current 1st aid and CPR and annual training on schedule for completion. LPA found that the staff require additional training on dementia care. LPA was informed that the training has been scheduled for this month. Licensee to ensure training for staff is completed by 9/8/2024. Technical Assistance. Lastly, A spot check of medications was conducted and found that all medication counts and records are in order.

Galina Knop's Administrator Certificate 7034765740 is currently active through 2/21/2025. Roman Knop's Administrator Certificate 7034766740 is currently active through 12/1/2025.

LPA requested the following documents be sent to CCL by COB 8/22/2024:

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: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/08/2024 12:31 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: PROVIDENCE PLACE	FACILITY NUMBER: 385600019
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 3 out of 10 reviewed Needs & Service Plans for residents (R1-R3) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit updated Needs & Service Plans for residents (R1-R3). In addition, to review all Needs & Service Plans for all residents ensuring that they are current. LIC9098 Proof of Corrections Form to be submitted by POC date 8/20/2024, indicating completion.

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: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

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