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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600377
Report Date: 08/28/2024
Date Signed: 08/28/2024 09:02:56 PM


Document Has Been Signed on 08/28/2024 09:02 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:MERCED GIRARD RESIDENTIAL CARE FACILITYFACILITY NUMBER:
385600377
ADMINISTRATOR:WU, JAMES O.DFACILITY TYPE:
740
ADDRESS:129 GIRARD STREETTELEPHONE:
(415) 467-8900
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:42CENSUS: 37DATE:
08/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Michael LeeTIME COMPLETED:
02:00 PM
NARRATIVE
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On 8/28/2024, Licensing Program Analysts (LPAs) Murial Han and Yi Sam Jian conduced an annual inspection. Upon entrance, LPAs were greeted by caregiver, Miao Fen Yu and LPAs explained the purpose of the visit. The administrator, Michael Lee arrived shortly thereafter and assisted with the inspection.

LPAs toured the facility. This facility is 3 floors and a basement level. There are no obstructions blocking indoor and outdoor passageways. No pools or bodies of water observed. Backyard is fenced, secured, and in good condition. Facility temperature is comfortable measured at 72F per thermostats observed and lighting is sufficient for comfort. Resident rooms are on the 1st, 2nd and 3rd floor with double occupancy.

Extinguishers last inspected on 6/18/2024 and emergency drills were reviewed.

Spare linens and blankets are observed. Cleaning solutions are stored and locked in basement level. LPAs reviewed 2 day perishable and 7 day nonperishable food supplies as in place. Additional food supplies are located in the basement level which contains 2 large freezers and additional canned and fresh produce.

Central stored medication, toxins and sharps objects were locked and inaccessible to residents.

A review of (6) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

During the tour with the administrator, LPAs observed a resident's over bed table has silver tape all around the edges, bathroom doors has chipped paint on the bottom, bathroom door frames have chipped paint and broken wood on the bottom, two of the kitchen cabinet doors are broken, a couch on the 2nd floor has silver tape around the right armrest, the toilet paper on the 3rd floor bathroom is held up by a plastic bag, broken floor in front of a resident's room on the 2nd floor and multiple chipped doors and door frame edges through-out the facility.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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 08/28/2024 09:02 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: MERCED GIRARD RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as water temperature was measured at 84-94 degrees F in the kitchen and resident bathrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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The administrator will develop a plan to ensure water temperature is within range and will submit a copy of the plan to CCL by 8/29/2024.
Type A
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents have bed rails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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The administrator will develop a plan to ensure a physician's order is obtained for residents who have bed rails by the head of the bed and will submit a copy of the plan to CCL by 8/29/2024. The plan shall indicate when an order will be obtained and provide a copy of the physician's orders when obtained.
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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/28/2024 09:02 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: MERCED GIRARD RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600377

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPAs observed facility not in good repair by the bathroom, floors, furniture, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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The administrator will develop a plan to ensure facility is in good repair and in the plan, it shall include how often preventive maintenance rounds will be conducted to ensure the facility is safe and in good repair at all times. The plan shall indicate the dates that the facility will complete the repairs for the observations that were made by LPAs during today's visit. The administrator will submit a copy of the plan to CCL by 9/4/2024.
Type B
Section Cited
CCR
87506(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 6 out of 6 resident's appraisal needs and services plans were incomplete as they were not signed by either the facility representative, the resident and/or the RP or both which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/04/2024
Plan of Correction
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The administrator will develop a plan to ensure this does not happen again and will provide a copy of the plan and a copy of the completed appraisal needs and service plans to CCL by 9/4/2024.
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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: MERCED GIRARD RESIDENTIAL CARE FACILITY
FACILITY NUMBER: 385600377
VISIT DATE: 08/28/2024
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LPAs requested for the following documents to be submitted to CCL by 8/30/2024 to update the administrator: LIC 500, LIC 503, LIC 308, a written letter from the licensee appointing the administrator and a copy of the administrator certification or proof that it is in the process of being renewed.


Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator. A copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4