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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600350
Report Date: 12/27/2024
Date Signed: 12/27/2024 12:34:00 PM

Document Has Been Signed on 12/27/2024 12:34 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:GONZALES HOMEFACILITY NUMBER:
385600350
ADMINISTRATOR/
DIRECTOR:		GONZALES, ROGELIO & PROSPEFACILITY TYPE:
740
ADDRESS:2237 NORIEGA STREETTELEPHONE:
(415) 242-0848
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6CENSUS: 4DATE:
12/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Prospe Gonzales, LicenseeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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On 12/27/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver, Ruth Yep. Licensee, Prospe Gonzales was contacted and arrived later in the visit. The facility currently provides care for 4 residents 3 of which were present, none of which are receiving hospice services, none of which are bedridden and some of with a diagnosis of dementia.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers found throughout the facility were found to be charged. Smoke and carbon monoxide detectors found throughout the facility were also tested and in working order. The facility requested assistance with initiating fire inspection for a potential bedridden clearance in the downstairs bedroom. There are no residents that are currently diagnosed bedridden but facility is requesting for safety measures.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored in locked cabinets under kitchen sinks and garage, all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.

Residents that were present during the inspection were observed relaxing in their bedroom, watching television or out in the community. The facility encourages regular family visits and utilizes outings for resident activities. There is an outdoor patio with shade and large outdoor space for residents. All residents appear to have a positive relationship during visit and state that they find the level of care to be adequate.
Continued onto LIC809-C
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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Document Has Been Signed on 12/27/2024 12:34 PM - It Cannot Be Edited


Created By: Dominic Tobola On 12/27/2024 at 12:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALES HOME
FACILITY NUMBER: 385600350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review LPA found 3 out of 3 residnets' with dementia in need of updated physician's reports, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2025
Plan of Correction
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Licensee agrees to provide copies of all updated physican's reports for 3 out of 3 resdients to CCLD by POC date 1/17/2024.
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:Andrea Medlin
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


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: GONZALES HOME
FACILITY NUMBER: 385600350
VISIT DATE: 12/27/2024
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LPA conducted a sample file review for 4 residents and found 3 out of 3 residents with dementia in need of updated physician's reports. Upon a check for 3 out of 3 staff files, LPA found that caregiver staff have 1st aid and CPR certification on file. However, 3 out of 3 staff require documented annual training records. LPA will provide list of vendorized trainers for Licensee to be in compliance. Technical Violation issued. Lastly, upon a spot check of medications all medication counts and records are in order.

LPA requested the following documents be sent to CCL by COB 8/22/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Client’s/Resident’s
Liability Insurance
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/27/2024
LIC809 (FAS) - (06/04)
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