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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600358
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:38:07 PM


Document Has Been Signed on 08/13/2024 02:38 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:DAMENIK'S HOMEFACILITY NUMBER:
385600358
ADMINISTRATOR:MONTILLA, DANILO F.FACILITY TYPE:
740
ADDRESS:331 30TH AVENUETELEPHONE:
(415) 379-9051
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:12CENSUS: 11DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Matt Montilla, Administrator AssistantTIME COMPLETED:
02:45 PM
NARRATIVE
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On 8/13/2024, Licensing Program Analysts (LPA's) Tobola & Jian conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver Staff, Maria "Tess" Alday. Assistant Administrator, Matt Montilla was contacted and arrived later in the visit. The facility currently provides care for 11 residents, 1 of which are receiving hospice services and some of which with a diagnosis of dementia.

LPA's 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 Extinguisher was found to be last charged on 10/6/2023. Carbon monoxide detectors found in both upstairs and downstairs hallways, were tested and found to be functioning. Smoke detectors are inspected by local fire inspection agency with last inspection dated 1/26/2024.

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. LPA's however, observed multiple items including milk, fruits and eggs expired or with mold. Medications were observed unsecured in kitchen refrigerator, accessible to residents. Cleaning supplies and other toxins are safely stored in locked cabinets in the, bathroom, garage and under kitchen sinks, 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. Water measured at faucets accessible to residents measured between 106.7 and 109.4 degrees F and within regulation.

Residents that were awake during the inspection were observed interacting with staff in the common area, or in their bedroom resting. The facility encourages regular family visits and utilizes common and outdoor space for resident exercise and mobility. The outdoor patio is equipped with shade with sufficient space for resident use.
Continued onto LIC809-C
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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 08/13/2024 02:38 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: DAMENIK'S HOME
FACILITY NUMBER: 385600358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in multiple medication stored in kitchen refrigerator not properly secured and accessible to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Administrator immediately removed medicaitons from refrigerator and agrees to implement lockbox to properly store medications requiring refridgeration. Photo proof of corrections to be submitted to CCLD by POC date 8/14/2024.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review along with staff medication count, the licensee did not comply with the section cited above in 1 out of 1 resident medicaitons, with missing medication dose, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Licensee agrees to review regulation 87465 with staff and provide LIC9098 Proof of Corrections form ensuring facility will remain in compliance. Form to be submitted to CCLD by POC date 8/14/2024.
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 MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/13/2024 02:38 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: DAMENIK'S HOME
FACILITY NUMBER: 385600358

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(23)
General Food Service Requirements
(b) The following food service requirements shall apply: (23) All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in mulitiple milk cartons and fruits to be expired or have mold growth, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee agrees to remove all food items that are past expiration or spoiled and submit LIC9098 Proof of Corrections form indicating faciltiy will remain in compliance by POC date 8/20/2024.
Type B
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 auditory alarms found to be inoperable, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/20/2024
Plan of Correction
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Licensee agrees to install updated auditory alarms and submit photo proof of corrections by POC date 8/20/2024.
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 MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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: DAMENIK'S HOME
FACILITY NUMBER: 385600358
VISIT DATE: 08/13/2024
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During inspection LPA's observed 2 auditory alarms in resident bedrooms inoperable, and is required for residents with dementia. LPA conducted a sample file review for 4 residents and found all items to be in order. LPA's provided technical support on facility to provide additional information on resident Needs & Service Plans. Technical Violation. Upon a sample review of staff files, LPA's found all staff to have 1st aid and CPR and annual training up to date. Lastly, during a spot medication check, LPA's found that 1 out of 1 resident was missing a single dose of prescribed medication. In addition, facility was found to have pre-poured medication 2 days prior and not stored in original container.

During inspection, LPA's observed resident (R1) with a bedridden status but had recently graduated from hospice services. A physician's assessment for R1 was conducted today 8/13/2024 with pending physician's report. LPA to follow up on R1's ambulatory status and determine findings at a later date.

Danilo Montanilla's Administrator Certificate 7035451740 is currently active through 11/26/2024.

LPA requested the following documents be sent to CCL by COB 8/27/2024:

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
Pest Control Receipt

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024
LIC809 (FAS) - (06/04)
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