385600382-5-9-2024-14-AS-JCAA-D54RFS-20240509125936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600382
Report Date: 05/09/2024
Date Signed: 05/09/2024 12:59:42 PM

Document Has Been Signed on 05/09/2024 12:59 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:	CARE AND CARE RESIDENCE II		FACILITY NUMBER:	385600382
ADMINISTRATOR:	NEVAREZ, JOSE		FACILITY TYPE:	740
ADDRESS:	901 GRAFTON AVENUE		TELEPHONE:	(415) 715-8400
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94112
CAPACITY:	6	CENSUS: 4	DATE:	05/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Lucila Panganiban, Caregiver		TIME COMPLETED:	01:00 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 May 9, 2024, at 8:45 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required visit. LPA Calandra was greeted by Lucila Panganiban, Caregiver and explained the purpose of the visit. LPA Calandra toured the physical plant. This is a 3-story building which consists of a kitchen, living room, dining room, 3 bedrooms, a staff bedroom downstairs, backyard, and 2 full bathrooms. All hallways, passageways, and the backyard were observed to be free of hazards and obstructions. All bedrooms had the required furniture and sufficient lighting. The facility was maintained at a comfortable temperature of 74 degrees Fahrenheit. Hot water temperature in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were equipped with the required grab bars and floor mats. Fire Alarms and Carbon Monoxide detectors in the facility were observed to be in working condition. Fire extinguishers were observed to be fully charged and a copy of the purchase receipt was provided to the LPA by caregiver, Lucila Panganiban. All food was observed to be in good condition. No food was expired. The facility had the required 7 days of non-perishables and 2 days of perishables on site. The washer and dryer were observed to be in working condition. All soap, detergent, and cleaning supplies were observed to be locked and in-accessible to persons in care. All knives and sharp objects were observed to be locked and in-accessible to persons in care. LPA Calandra reviewed 4 client records and 5 staff records. All client records were observed to have incomplete LIC 602-Physician's reports that were unsigned. LPA Calandra interviewed 2 residents and 1 staff member.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

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: CARE AND CARE RESIDENCE II	FACILITY NUMBER: 385600382
	VISIT DATE: 05/09/2024

NARRATIVE

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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(CSMR) kept at the facility.

LPA Calandra requested the following documents be sent to the department:

-The facility's Liability Insurance
-The facility's current lease agreement
-Updated LIC 500
-LIC 503/Health Screening Reports for all staff

Type B Violations were provided for incomplete Physician's reports and dressers in resident bedrooms that were in disrepair.

A Technical violation was provided for not having a facility sketch that shows evacuation routes.

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.

This report was reviewed with Lucila Panganiban, Caretaker and a copy of the report along with Appeal Rights left at the facility.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/09/2024 12:59 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: CARE AND CARE RESIDENCE II	FACILITY NUMBER: 385600382
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(a)

Medical Assessment

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	CCR 87458(a): Medical Assessment: Based on record review, the licensee did not comply with the section cited above in 4 out of 4 resident records, which were incomplete and missing signatures from the resident's physician, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2024
	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

87303(a)

(a) 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
1 2 3 4	87303(a): Maintenance and Operations: Based on observation, the licensee did not comply with the section cited above in 5 out of 7 dressers and end tables which were observed to be in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/23/2024
	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 to licensing in the future 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: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024

LIC809 (FAS) - (06/04)

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