385600167-3-29-2024-14-AS-JCAA-D3TS2D-20240329132923

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600167
Report Date: 03/29/2024
Date Signed: 03/29/2024 01:29:29 PM

Document Has Been Signed on 03/29/2024 01:29 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:	03/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Nancy		TIME COMPLETED:	01:30 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 March 29, 2024 at 9:25 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Nancy Supetran, Caregiver and explained the purpose of his visit. LPA Calandra also called and spoke with Administrator, Renelee So who was unavailable to join the visit and explained the purpose of his visit. LPA Calandra toured the physical plant. This is a 1 story building with 3 bedrooms, 2 bathrooms, a kitchen, dining room and living room. The facility was maintained at a comfortable temperature of 70 degrees Fahrenheit. No accessible bodies of water or hazards were observed in hallways or the backyard. The facility's fire extinguishers were observed to be fully charged and last checked on 11/8/2023. The facility's fire and Carbon Monoxide detectors were observed to be in working order. All bedrooms had sufficient lighting and the required furniture. Night lights were observed to be in working condition in the hallway. Hot water temperature was measured at 113.3 degrees Fahrenheit well within the required range of 105-120 degrees Fahrenheit. No food was expired. The facility has the required 7 days of non-perishables and 2 days of perishables on site. The Washer and Dryer were observed to be in good repair. All sharp objects, detergent, poisons, and medications were locked up and in-accessible to persons in care. All Personal & Incidental(P&I) money kept at the facility matched facility records. LPA Calandra reviewed 5 client files. All were observed to be complete except for two which were missing pre-admission appraisals. LPA Calandra also reviewed 5 staff files. All were observed to be complete. 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: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

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: 9TH AVENUE COMMUNITY CARE HOME	FACILITY NUMBER: 385600167
	VISIT DATE: 03/29/2024

NARRATIVE

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LPA Calandra interviewed 2 clients and 1 staff member.

A Type B violation was provided for not completing a pre-admission appraisal for R1 and R2.

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

This report was reviewed with Nancy Supetran, Caregiver and a copy of the report 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: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/29/2024 01:29 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: 03/29/2024

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	CCR 87457(c): Pre-Admission Appraisal: Based on record review, the licensee did not comply with the section cited above in 2 out of 5 client records, which were observed to be missing Pre-Admission Appraisals, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/12/2024
	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: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC809 (FAS) - (06/04)

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