<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600383
Report Date: 06/24/2021
Date Signed: 07/21/2021 03:36:04 PM

Document Has Been Signed on 07/21/2021 03:36 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CARE AND CARE RESIDENCE IFACILITY NUMBER:
385600383
ADMINISTRATOR:JOSE NEVAREZFACILITY TYPE:
740
ADDRESS:940 HAIGHT STREETTELEPHONE:
(415) 829-2775
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 14CENSUS: 14DATE:
06/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Caregiver, Michelle PerezTIME COMPLETED:
02:50 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 6/24/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual required inspection. LPA met with Caregiver, Michelle Perez.

At 10:20am, LPA arrived at facility and was greeted by staff. LPA observed COVID-19 signs posted on the front entry point and staff took LPA's temperature but the facility ran out of the symptom review questionnaire so it was done on a piece of blank paper.

At 10:30 am, LPA reviewed the COVID-19 logs and it indicated that the resident/staff daily monitoring log was last completed in December 2020; the last documented visitor screening questionnaire was completed on 3/24/2021 and the staff stated that they were never tested for COVID-19 except for the Administrator.

At 11:00 am, LPA toured the facility beginning in the dining room and observed 2 sofas that are spaced out to promote social distancing. COVID-19 Infection Control signs are posted in the living/dining room but not in the hallway. LPA recommended to post COVID-19 signs in the hallway as well. There were residents watching TV without face covering. The caregiver stated that everyone has been vaccinated and it is a challenge to ask the residents to wear face covering but they will continue to encourage them to do so. Hand washing stations were equipped with paper supplies and soaps. The facility has two patios that are designated visitation areas. Both patios do not have any COVID-19 signs posted and LPA recommended to post signs in the patios. Patio 2 has three chairs that are not 6" apart and LPA recommended to remove one of them or put an "X" in the middle chair to ensure social distancing is maintained. Trash bins were observed equipped with foot operated lids. The bed rooms were observed to be furnished per Title 22 regulations. Beds were spaced at least 6 feet apart or 3 feet apart with head-to-toe orientation. Food supply was checked and observed to be sufficient. Medication cabinet was observed to be sufficient.

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.

This report was reviewed, discussed with caregiver, Michelle Perez and over the phone with the Administrator, Marlon Sicat. A copy is provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/24/2021
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 2
Document Has Been Signed on 07/21/2021 03:36 PM - It Cannot Be Edited


Created By: Murial Han On 06/24/2021 at 01:49 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: CARE AND CARE RESIDENCE I
FACILITY NUMBER: 385600383

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not comply with the section cited above as the staff and resident daily COVID-19 monitoring log was last completed in December 2020, the visitor symptom review questionnaire was last completed on 3/24/21, and the staff members were never tested for COVID-19 except for the Administrator, Marlon Sicat. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2021
Plan of Correction
1
2
3
4
The Administrator will review the CCLD PINs relating to staff COVID-19 testing, daily visitor/resident screening/monitoring and visitor screening then proceed accordingly. The Administrator will educate the staff on the above requirements and will submit a copy of the sign-in sheet and the content of the education to CCLD by POC 7/1/2021.
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:Brenda Chan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2