385600141-10-20-2023-14-AS-APAA-CWT224-20231020170003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600141
Report Date: 10/20/2023
Date Signed: 10/20/2023 05:00:54 PM

Document Has Been Signed on 10/20/2023 05:00 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:	AUTUMN GLOW		FACILITY NUMBER:	385600141
ADMINISTRATOR:	JAMES WONG		FACILITY TYPE:	740
ADDRESS:	654 GROVE STREET		TELEPHONE:	(415) 934-1622
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	15	CENSUS: 15	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Kit Fong		TIME COMPLETED:	05:00 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 10/20/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived to this facility unannounced to conduct an annual visit. LPA was greeted by Assistant Administrator, Jane Mak and explained the purpose of the visit. This facility is licensed to hold up to 15 residents who are 60 and older. 15 out 15 residents may be non-ambulatory. This facility also holds a dementia plan on file and has a hospice waiver for 2. Shortly after, LPA met with Facility Designated Administrator (FDA), Kit Fong. Current census was 15. A brief interview with (AM) Mak was conducted. LPA reviewed 6 resident files and 5 staff files. The Facility Designated Administrator, Kit Fong, has a current and active administrator certificate #6063650740 and expires on 08/05/2024. 6 out 6 residents files were missing the LIC 613-safeguard for personal valuables and personal rights. 2 out 6 resident files did not have an updated Physicians report. 4 out 5 staff files were current and up to date. 1 out 5 staff files did not have a current first aid certificate. A tour of the facility was conducted. This facility has 3 floors and a roof top terrace. The facility elevator was last serviced on 02/02/2023 and is valid until 02/02/2024. The facility was last serviced by AU Electric Coporation to ensure that smoke alarms, carbon monoxide detectors and the Fire System was in working condition. A tour of the basement floor was conducted. Office area was toured. A tour of the laundry room was conducted. Toxins and cleaning supplies were observed to be inaccessible to the residents in care. A medication cart was observed next to the laundry room. Along with the FDA and AM, LPA compared medication to medication dispensing logs. First Aid kit was present and had all the required components. Tour of the kitchen was toured. LPA observed a sufficient amount of 2 day perishable and 7 day nonperishable food supply for the residents in care. A tour of the resident lounge was conducted. Furniture and furnishings were observed to be in good repair at this time. A tour of the 1st floor and 2nd floor was conducted. Each floor holds a fire extinguisher that was services by AAA restuarant on 08/02/2023 and was observed to be in compliance at this time. Each floor also has 4 resident bedrooms. Furniture and furnishings were observed to meet the residents needs at this time.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2023

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: AUTUMN GLOW	FACILITY NUMBER: 385600141
	VISIT DATE: 10/20/2023

NARRATIVE

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This facility holds 2 resident bathrooms on each floor. Hot water temperature was observed was taken to ensure that it dispensed water between 105 to 120 degrees.
A tour of the facility roof was conducted.
A tour of the perimeter was conducted with no hazards present. Perimeter fence and gates were observed to be in good repair.

The following documents were requested to updated and sent to CCL:
-LIC 308
-LIC 309
-LIC 400
-LIC 500
-LIC 610

Technical assistance is being provided today for the following sections: 87506(b) and 87465(h)(5)

Per California Code of Regulations (CCR) – Title 22 – Division 6, Chapter 6, deficiencies were observed during today’s visit. Citations can be found on the LIC 809 – D. Failure to correct deficiencies may result in civil penalties. Appeal Rights were provided to the facility. An exit interview was held, and a copy of the report was provided in-person.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/20/2023 05:00 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: AUTUMN GLOW	FACILITY NUMBER: 385600141
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87411(c)(1)

(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in by not ensuring that S1 did not have first aid training conducted and certification was on file. This poses an immediate health, safety and personal rights risks to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee shall ensure that S1 conducts first aid training by the POC date. A copy of S1's first aid certificate must be sent to the LPAs email by POC 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: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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