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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600076
Report Date: 10/21/2023
Date Signed: 10/21/2023 02:56:18 PM


Document Has Been Signed on 10/21/2023 02:56 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:STELLA'S CARE HOME IFACILITY NUMBER:
385600076
ADMINISTRATOR:CHANG, STELLAFACILITY TYPE:
740
ADDRESS:616 39TH AVENUETELEPHONE:
(415) 752-8652
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:12CENSUS: 9DATE:
10/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Margie ValeriaTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA met with facility staff Fernando, and explained the purpose of the visit. LPA was later met by current Administrator Margie E Valeria. Previous Administrator Stella Chang is no longer than administrator but is still the licensee of the facility. Based on an interview with Administrator Margie, Margie was appointed in 2017. Margie has an active Administrator Certificate: #6047120740 Exp. 02/22/2024.

LPA and facility staff toured the facility physical plant to ensure compliance with Title 22 regulations. The facility is a two story building. The stairs were equipped with a evacuation chair, which was observed to be in working condition. LPA observed bedrooms to have necessary furniture, to be in clean condition, and free from odors. Bathrooms were fully stocked with toilet paper, paper towels, soap, trash can, and skid mats. Faucets in the bathrooms delivering hot water measured a temperature of 115.3*degrees F, which is within the regulatory range. Common areas were observed to be clean and free from debris. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed medication cabinets on both floors to be unlocked. Facility staff locked the cabinet once LPA asked them to lock them up. LPA Valerio observed a pull alarm system with an inspection date of 03/06/23, fire extinguisher(s) with last check on 10/12/22, and smoke and carbon monoxide detectors. No emergency exits were obstructed. LPA reviewed resident and staff files. LPA observed 4 staff files to be up to date and training files to be current. All staff were observed to be fingerprint cleared. 3 out of 4 resident files reviewed were observed to be incomplete. Residents were observe eating their lunch (chicken/fish, vegetables, rice, fruit, and drink), watching football, reading the paper, being assisted with ADLs, listening to gospel music, enjoying the weather in the backyard. LPA requested the following updated copies to be sent to the Regional Office: LIC 500, LIC 308 Designation of Administrative Responsibility, Liability Insurance, Proof of Control of Property, LIC 9282 Infection Control Plan, and LIC 610D Emergency Disaster Plan
Per the California Code of Regulations, Title 22, Division 6, deficiencies were observed or cited on the LIC 809-D page. Appeal Rights provided. Exit interview held and a copy of the report was provided.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


Document Has Been Signed on 10/21/2023 02:56 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: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 medication cabinets were observed to be unlocked during LPA's visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2023
Plan of Correction
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Licensee had administrator lock up all the cabinets/drawers to ensure residents did not have access to medications. LPA observed the medications locked by the end of the visit. Administrator will conduct an in-service with all staff regarding the lock for the medication. LPA to receive in-service sign in sheet by POC due date.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2023
Plan of Correction
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Licensee had administrator lock up all the cabinets/drawers to ensure residents did not have access to medications. LPA observed the medications locked by the end of the visit. Administrator will conduct an in-service with all staff regarding the lock for the medication. LPA to receive in-service sign in sheet by POC due date.
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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 10/21/2023 02:56 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: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87467(a)(3)
Resident Participation in Decisionmaking
(a) Prior to, or within two weeks of the resident's admission, 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, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, the licensee did not comply with the section cited above in 3 out of 3 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/21/2023
Plan of Correction
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Licensee to ensure all resident files are completed with required documentation by POC due date. Administrator to send confirmation of completion by POC due date.

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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/21/2023 02:56 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: STELLA'S CARE HOME I
FACILITY NUMBER: 385600076

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203
87203 Fire Safety 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 3 out of 3 fire extinguishers, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/22/2023
Plan of Correction
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Licensee stated administrator will obtain a fire extinguisher that is within compliance by POC due date. Administrator stated she scheduled the fire marshall to come out on 10/23/23 to service the fire extinguishers.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina ValerioTELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5