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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600383
Report Date: 06/12/2024
Date Signed: 06/12/2024 03:52:21 PM

Document Has Been Signed on 06/12/2024 03:52 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 IFACILITY NUMBER:
385600383
ADMINISTRATOR/
DIRECTOR:		JOSE NEVAREZFACILITY TYPE:
740
ADDRESS:940 HAIGHT STREETTELEPHONE:
(415) 829-2775
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 14CENSUS: 12DATE:
06/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Michelle Perez, Caregiver TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On June 12, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:30 AM to conduct the unnanounced Annual 1-year required inspection. LPA Calandra was greeted by Michelle Perez, Caregiver and explained the purpose of the visit. Arlene Gomez, Administrator was contacted by phone but could not join the visit.

LPA Calandra toured the physical plant. This is a 1-story building which consists of 7 bedrooms, two bathrooms, a backyard, a staff bedroom, and storage room. All bedrooms had the required furniture and sufficient lighting. All bathrooms had the required grab bars and non-skid floor mats. No accessible bodies of water or hazards were observed. The facility temperature was set to 70 degrees Fahrenheit. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The fire extinguishers were observed to be fully charged and last inspected by the fire department on January 11, 2023. At 1:00 PM, Michelle Perez, Caretaker showed LPA Calandra the 2024 fire extinguishers which were observed to also be fully charged. The facility's first aid kit was observed to have the required sterile first aid dressings, bandages, scissors, tweezers, and thermometers. The facility's smoke and carbon monoxide detectors were observed to be in working order.Per a conversation with Jay Navarez on the phone at 10:24 AM, the smoke and carbon monoxide detectors are connected directly to the San Francisco Fire Department.

All sharp objects, poisons, soaps, and detergents were observed to be locked and in-accessible to persons in care.

LPA Calandra reviewed 5 resident files and 5 staff files. Resident files were observed to have incomplete documents such as the LIC 602: Physician's report and Annual Needs and Services Plan. Staff files were observed to have incomplete LIC 503: Health Screening Reports and TB results.

LPA Calandra interviewed 4 residents and 3 staff.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/12/2024
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 I
FACILITY NUMBER: 385600383
VISIT DATE: 06/12/2024
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.

A Type A violation was provided for not having TB results for S1, S2, and S3.

A Type A violation was provided for not conducting emergency drills quarterly per shift and documenting those drills.

A Type B violation was provided for not fixing the ceiling in Bedroom 7 which per an interview had retained water damage from the latest storms.

A Type B violation was provided for not having a medical assessment for R1.

A Type B violation was provided for not having Annual Needs and Services Plans for R1, R2, R3, R4, and R5.

LPA Calandra requested the following documents be sent to the Regional Office:

-Updated LIC 500
-Current Lease Agreement
-Administrator Certificate

The Annual inspection will be completed at a later date.

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 Michelle Perez, Caregiver and an exit interview conducted. A copy of the report along with appeal rights were left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 06/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 06/12/2024 03:52 PM - It Cannot Be Edited


Created By: John Calandra On 06/12/2024 at 02:19 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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87411-Personnel Requirements-General: Based on record review, the licensee did not comply with the section cited above in 3 out of 6 staff files that had incomplete LIC 503: Health Screening Reports that did not show whether a TB test had been performed nor the results, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 06/12/2024 03:52 PM - It Cannot Be Edited


Created By: John Calandra On 06/12/2024 at 02:19 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation and record review, the licensee did not comply with the section cited above in 5 out of 12 resident records, which did not have completed Annual Needs and Services Plans, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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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
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4
POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 06/12/2024 03:52 PM - It Cannot Be Edited


Created By: John Calandra On 06/12/2024 at 02:52 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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3
4
Type A
Section Cited
HSC
1569.695(c)


1569.695(c): Emergency Plans: A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is notrequired during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
Deficient Practice Statement
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Based on interview with the Administrator , the licensee/Administrator did not comply with the section cited above in 1 out of 1 instances in which they do not have record of an emergency drill being conducted since 2022, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 06/12/2024 03:52 PM - It Cannot Be Edited


Created By: John Calandra On 06/12/2024 at 03:10 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)

87458(a) Medical Assessment: 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.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 12 resident records, which did not have a completed LIC 602: Physician's order, which poses/posed a potential health, safety or personal rights risk to persons in care.

POC Due Date: 06/26/2024
Plan of Correction
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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
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4
POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 06/12/2024 03:52 PM - It Cannot Be Edited


Created By: John Calandra On 06/12/2024 at 03:14 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: 06/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operations: (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
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1 bedroom ceilings which was observed to have been been damaged, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/26/2024
Plan of Correction
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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 the licensing office by the due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
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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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 06/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/12/2024


LIC809 (FAS) - (06/04)
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