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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
385600350
Report Date:
01/30/2024
Date Signed:
01/30/2024 04:26:15 PM
Document Has Been Signed on
01/30/2024 04:26 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 HOME
FACILITY NUMBER:
385600350
ADMINISTRATOR:
GONZALES, ROGELIO & PROSPE
FACILITY TYPE:
740
ADDRESS:
2237 NORIEGA STREET
TELEPHONE:
(415) 242-0848
CITY:
SAN FRANCISCO
STATE:
CA
ZIP CODE:
94122
CAPACITY:
6
CENSUS:
4
DATE:
01/30/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:16 AM
MET WITH:
Prosperidad Gonzales, Administrator and Manolito Torres, Caregiver
TIME COMPLETED:
04:30 PM
NARRATIVE
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On January 30, 2024 at 9:16 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the unnanounced Annual 1-year required inspection. LPA Calandra was greeted by Manolito Torres, Caregiver at the door and explained the purpose of his visit. Administrator, Prosperidad Gonzales joined the visit later.
LPA Calandra toured the physical plant. This is a 2-story building that consists of bedrooms and 2 bathrooms(1 for residents and 1 for staff). Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. The resident bathroom was observed to have the required grab bar and anti-skid mat. Fire extinguishers in the facility were observed to be fully charged and last checked on March 7, 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 is being maintained at a comfortable temperature of 70 degrees Fahrenheit. The facility's first aid kit was observed to be complete. The facility does not handle any cash resources at this time.
LPA Calandra reviewed 4 resident records and 5 staff records. Documents missing include signed Consent Forms, Needs and Services Plans, LIC 602s, etc.
All knives and sharp objects were observed to be locked and in-accessible to persons in care.
All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care.
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:
01/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
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
18
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:
01/30/2024
NARRATIVE
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LPA Calandra requested the following documents from the facility be sent via email or fax to the RO:
-Administrator Certificates
-Theft and Loss Policy
-Liability Insurance
-LIC 309-Administrative Organization
-Control of Property
-Designation of Facility Responsibility
During the physical plant tour, LPA Calandra observed a resident who appeared to be bedridden. After an interview with the Licensee/Administrator and R1, LPA Calandra determined that this resident fits the definition of bedridden. LPA Calandra contacted support staff to request a copy of the facility's current fire clearance. The latest fire clearance does not state that bedridden persons can reside in the facility. LPA Calandra discussed with the Administrator that the facility is currently operating outside of their license and that the facility will be cited for this.
Additionally, during an interview with the Licensee, LPA Calandra learned that the facility had a client on oxygen. LPA Calandra asked the Licensee if the fire department had been notified and was told they have not.
During today's visit the facility was cited for accepting and retaining a bedridden resident without obtaining and maintaining appropriate fire clearance, not including in their plan of operations how the facility plans to care for bedridden residents, failure to have an emergency disaster plan which addresses fire safety precautions specific to evacuation of bedridden residents, staff records not including documentation of staff training related to the care of bedridden residents, and for the use of bed rails without a doctor's written order, and failing to provide on-the-job training to staff who care for residents with Dementia, and failure to complete a medical assessment, and reappraisal for residents on an annual basis.
Technical violations were provided for failure to have a written request for acceptance or admittance to or retention in the facility, while receiving hospice services, failing to have an auditory device or other staff alert feature to monitor exits.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
John Calandra
TELEPHONE:
650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
2
of
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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:
01/30/2024
NARRATIVE
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A Type A violation was provided for failure to obtain fire clearance for bedridden resident.
A Technical violation was provided for retaining a bedridden resident and not including additional information in the plan of operations.
Deficiencies are cited under California Code of Regulations, Title 22, cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.
The report was reviewed with Licensee/Administrator, Prosperidad Gonzales and a copy along with Appeal rights was 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:
01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
3
of
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Document Has Been Signed on
01/30/2024 04:26 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:
GONZALES HOME
FACILITY NUMBER:
385600350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with the resident and Licensee/Administrator, and record review of facility's fire clearance, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/31/2024
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.
Type A
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Licensee/Administrator and record review of facility fire clearance, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/31/2024
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.
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:
01/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
4
of
18
Document Has Been Signed on
01/30/2024 04:26 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:
GONZALES HOME
FACILITY NUMBER:
385600350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87618(b)(3)(A)
Oxygen Administration - Gas and Liquid
(3) Ensuring that the use of oxygen equipment meets the following requirements: (A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Licensee/Administrator, the licensee did not comply with the section cited above in 1 out of 1 persons, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/31/2024
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.
Type A
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
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1 out of 1 persons which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/06/2024
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.
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:
01/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
5
of
18
Document Has Been Signed on
01/30/2024 04:26 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:
GONZALES HOME
FACILITY NUMBER:
385600350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(1)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Licensee/Administrator and record review of facility's plan of operation, the licensee did not comply with the section cited above in 1 out of 1 plans of operation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/07/2024
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.
Type B
Section Cited
CCR
87606(f)(1)(A)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (1) The facility's Plan of Operation includes a statement of how the facility intends to meet the overall health, safety and care needs of bedridden persons. (A) The facility's Emergency Disaster Plan, addresses fire safety precautions specific to evacuation of bedridden residents in the event of an emergency or disaster.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview of Licensee/Administrator, the licensee did not comply with the section cited above in 1 out of 1] persons which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/07/2024
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.
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:
01/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
6
of
18
Document Has Been Signed on
01/30/2024 04:26 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:
GONZALES HOME
FACILITY NUMBER:
385600350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview with Licensee/Administrator, the licensee did not comply with the section cited above in 5 out of 5 staff which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/07/2024
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.
Type B
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation of resident in bed utilizing half bed rail and record review, the licensee did not comply with the section cited above in 1 out of 1 persons, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/07/2024
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.
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:
01/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
7
of
18
Document Has Been Signed on
01/30/2024 04:26 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:
GONZALES HOME
FACILITY NUMBER:
385600350
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
01/30/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview with Licensee/Administrator, the licensee did not comply with the section cited above in 5 out of 5 staff, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/07/2024
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:
01/30/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/30/2024
LIC809
(FAS) - (06/04)
Page:
8
of
18