385600076-2-21-2024-14-AS-JCAA-D2NUJQ-20240221143754

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600076
Report Date: 02/21/2024
Date Signed: 02/21/2024 02:37:59 PM

Document Has Been Signed on 02/21/2024 02:37 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 I		FACILITY NUMBER:	385600076
ADMINISTRATOR:	MARGIE VALERIA		FACILITY TYPE:	740
ADDRESS:	616 39TH AVENUE		TELEPHONE:	(415) 752-8652
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	12	CENSUS: 10	DATE:	02/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Margie Valeria, Administrator		TIME COMPLETED:	02:45 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 February 21, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 10:15 AM to conduct the Annual-1 year required visit. LPA Calandra met with Margie Valeria, Administrator and explained the purpose of his visit. LPA Calandra toured the physical plant. This is a two story building that consists of 8 bedrooms and 3 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last inspected on October 23, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility does not handle cash resources. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. All knives, sharp objects, soaps, detergents, and medications were observed to be locked and in-accessible to persons in care. LPA Calandra reviewed 5 resident files and 5 staff files. All staff files were observed to be complete. R1's file was missing the Annual Needs and Services Plan. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

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: STELLA'S CARE HOME I	FACILITY NUMBER: 385600076
	VISIT DATE: 02/21/2024

NARRATIVE

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Technical Violations(TV) were provided for failing to conduct an emergency drill at least quarterly per shift and not including in their plan of operation information about accepting/retaining residents with dementia.

During today's visit, the facility was cited for not including an appraisal of a resident's individual needs and service in comparison with the admission criteria.

The following documents were requested during today's visit:

-Liability Insurance
-Updated LIC 500
-Updated LIC 400
-Facility sketch showing evacuation routes
-Updated designation of facility responsibility-LIC 308

Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

This report was reviewed with Margie Valeria, Administrator, and a copy along with appeal rights left at the facility.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/06/2024 02:40 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 03/05/2024 04:10 PM

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: 02/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87457(c)

Pre-Admission Appraisal

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This is an Amended document CCR 87457(c): Based on records review, the licensee did not comply with the section cited above in 1 out of 1 resident files, in which no appraisal of the resident's individual services needs was present, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/04/2024
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024

LIC809 (FAS) - (06/04)

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