385600167-10-1-2023-14-AS-CVAO-CW7VG8-20231001162508

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600167
Report Date: 10/01/2023
Date Signed: 10/01/2023 04:25:22 PM

Document Has Been Signed on 10/01/2023 04:25 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:	9TH AVENUE COMMUNITY CARE HOME		FACILITY NUMBER:	385600167
ADMINISTRATOR:	DIMAYUGA, A & VALENCIANO,		FACILITY TYPE:	740
ADDRESS:	1730 - 9TH AVENUE		TELEPHONE:	(415) 759-5825
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	6	CENSUS: 5	DATE:	10/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:56 PM
MET WITH:	Nancy Supetran		TIME COMPLETED:	04:45 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	Licensing Program Analyst (LPA) Christina Valerio and LPA Arielle Pascua arrived to the facility unannounced to conduct a facility annual inspection. LPAs met with facility staff Nancy Supetran, and explained the purpose of the visit. According to facility staff, the Licensee and Administrator is currently out of town. LPAs toured the physical plant to ensure compliance with Title 22 regulations. The facility is a three story building. The facility's first and second floor are the licensed areas of the home. LPAs toured the first floor and the second floor of the facility. The first floor appears to be utilized for storage, emergency supplies, and a private area for staff. According to facility staff, the licensee never utilized the bottom floor for residents. The second floor had 4 resident bedrooms, 2 resident bathrooms, a kitchen area, and dinning area. Resident bedrooms were observed to be fully furnished with a bed, night stand, chair, dresser, and closet space. In bedrooms 4, bedroom 2, bedroom 1, and the dinning area, LPAs observed pee pads on the top of chairs, bedding, and the floor of the bathroom. According to staff, this is used to prevent any bodily fluids and is changed every morning. LPAs observed the resident bathrooms. Hot water was measured at 117.0degrees, which is within regulatory range of 105-120F. A fully charged fire extinguisher with an annual inspection of 05/09/2022, carbon monoxide detector, and air conditioning was observed to be in working condition. The kitchen area was observed to be locked. According to a phone conversation with Licensee Renelee So and facility staff Nancy, the facility has always had the kitchen locked, which Golden Gate Regional Center has been in agreement with implementing this. LPAs informed the licensee that the department does not have an approved waiver to have the kitchen/food items locked and inaccessible to residents in care. Medications, cleaning supplies, and sharps were observed to be locked and inaccessible to residents in care. Continues on LIC 809 -D...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
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)

Page: 1 of 5

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: 9TH AVENUE COMMUNITY CARE HOME	FACILITY NUMBER: 385600167
	VISIT DATE: 10/01/2023

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
26
27
28
29
30
31
32

...Continued from LIC 809

LPAs reviewed 5 resident files for Resident 1 (R1) - Resident 5 (R5). Resident files were observed to be incomplete. R1 - R5's file did not have an updated Appraisal, LIC 602, or Individual Program Plan (IPP) on file. R2's LIC 602 had a diagnosis of dementia. According to the Regional Office File Review, the facility does not have an approved Dementia Care Plan nor are they licensed to serve individuals with dementia. Training related to dementia care were not observed in the staff training section. The facility's last Fire Drill was conducted with residents during September of 2023. An updated surety bond policy was observed.

LPAs reviewed 3 staff files. Two staff observed working in the facility were observed to be fingerprinted and cleared. Staff had an up to date First Aid Certificate. Licensee Renelee and Facility staff Nancy stated that the administrator changed a few years ago. Licensee Renelee So is the designated administrator. Administrator Certificate #6011479740 Expiration 03/20/2024. TA was provided to facility staff. The licensee will send updated information to change Administrator to the Regional Office.

LPA requested the following documentation be sent to the Regional Office:
Control of Property
LIC 308 - Designation of Facility Responsibility
LIC 999 - Facility Sketch
Liability Insurance
Qualifications of Administrator
Surety Bond
LIC 500
LIC 601D - Emergency Disaster Plan

Per California Code of Regulations (CCR) - Title 22, Division 6, deficiencies are being cited today on the attached LIC 809 - D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of the report was provided to facility staff Nancy.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
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

LIC809 (FAS) - (06/04)

Page: 2 of 5

Document Has Been Signed on 10/01/2023 04:25 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: 9TH AVENUE COMMUNITY CARE HOME	FACILITY NUMBER: 385600167
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87470(a)(4)(A)1

Infection Control Requirements

(a) A licensee shall ensure that infection control practices are maintained as follows: (4) All facility staff and volunteers shall use gloves as a protective barrier to prevent the spread of potential infection as specified below. (A) Gloves shall always be worn when: 1. Coming into contact with blood or body fluids or other potentially infectious material such as saliva, stool, vomit or urine. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, 3 out of 4 bedrooms, resident bathrooms, and common areas were observed to have used pee pad, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Licensee had facility staff removed all the used pee pads. Licensee to review Infection Control Requirements and send a plan to LPA by POC due date. The plan will describe how the facility will ensure the pee pads will not be used by more than 1 resident.

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee stated they always had the kitchen locked and inaccessible to clients, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/02/2023
	Plan of Correction
1 2 3 4	Licensee will send a Waiver Request to LPA 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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2023

LIC809 (FAS) - (06/04)

Page: 3 of 5

Document Has Been Signed on 10/01/2023 04:25 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: 9TH AVENUE COMMUNITY CARE HOME	FACILITY NUMBER: 385600167
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(c)

Plan of Operation

(c) A licensee who accepts or retains residents diagnosed by a physician to have dementia shall include additional information in the plan of operation as specified in Section 87705(b). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review,, the licensee did not comply with the section cited above in 1 out of 4 resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee to send an updated Plan of Operation to include Care for Residents with Dementia.

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 records review, the licensee did not comply with the section cited above in 5 out of 5 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee to update LIC 602, Appraisals/Needs and Service Plan, and IPPs for all resident files. LPA to receive notification and copies of documentation 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 Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5