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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600383
Report Date: 12/10/2023
Date Signed: 12/10/2023 03:07:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/10/2023 03:07 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:JOSE NEVAREZFACILITY TYPE:
740
ADDRESS:940 HAIGHT STREETTELEPHONE:
(415) 829-2775
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 14CENSUS: 12DATE:
12/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Elvis PerezTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/10/23 at 11AM to conduct a Required -1 Year visit. LPA met with Caregiver Elvis Perez and stated the purpose of the visit. Caregiver contacted Michelle Perez, Caregiver regarding todays visit. Administrator certificate expired 5/18/23 for Arlene Gomez. LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. LPA was allowed entry into the facility that is licensed to serve 14 residents of which 6 maybe non-ambulatory in rooms 1, 4, & 5. Facility staff roster provided during this visit. The physical plant was toured inside and outside to ensure the safety of the clients. LPA observed the staff and residents preparing for lunch. LPA observed a pull alarm fire system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. The temperature inside the facility was measured at 68*F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature. The hot water temperature was measured at 118.4 *F which is within the required range of 105-120*F. LPA observed during this visit regarding the first aid kit: sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, however the following were not made available: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. LPA observed 2 staff and 2 resident records during this visit. During file review LPA observed expired first aid/CPR certificates for staff and no results for TB.

-LPA did not observed an LIC308 Designation of Responsibility as designee on file was sleeping during this visit.
-LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal.
-LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution.
-LPA did not observe TB results for staff.


See 809C for continuation...
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2023
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: 12/10/2023
NARRATIVE
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809 continued...

-LPA inquired with both staff regarding the Infection Control Plan. LPA did not receive an answer from either.
-LPA observed medications belonging to staff accessible and on top of refrigerator not locked.
- During file review LPA observed expired first aid/CPR certificates for staff.
-LPA observed screen at front of facility window to be not in good repair.
-LPA observed records of residents incomplete, without signatures and dates

Upon a file review the following items were discussed to be submitted with any changes annually:
Infection Control Plan (LIC9282), updated Designation of Facility Responsibility (LIC308),
Liability Insurance, Control of Property such as rental agreement or lease agreement, Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610D).

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit.

If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.

An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2023
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Document Has Been Signed on 12/10/2023 03:07 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/10/2023 at 01:41 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: 12/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2023
Section Cited
CCR
87405(a)

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Administrator - Qualifications and Duties
All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section...
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Administrator/Licensee shall submit an updated LIC308 by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on: LPA did not observed an LIC308 Designation of Responsibility as designee on file was sleeping during this visit. This violation poses an immediate health, and safety risk to residents in care.
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Type A
12/11/2023
Section Cited
CCR87406(g)

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Administrator Certification Requirements
Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.
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Administrator/Licensee shall submit an updated Administrator Certificate and/or proof of completion by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on: LPA did not observe an Administrator certificate for Jose Nevarez nor supporting documents with proof of payment for renewal. This violation poses an immediate health, and safety risk to residents in care.
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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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2023


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Document Has Been Signed on 12/10/2023 03:07 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/10/2023 at 01:47 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: 12/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2023
Section Cited
CCR
87465(8)(A-F)

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Incidental Medical and Dental Care
If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:
A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency. Sterile first aid dressings. Bandages or roller bandages. Scissors. Tweezers. Thermometers.
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Administrator/Licensee shall submit proof a complete kit is on the premises by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on: LPA did not observe a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, tweezers, and antiseptic solution. This violation poses an immediate health, and safety risk to residents in care.
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Type A
12/11/2023
Section Cited
CCR87411(f)

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Personnel Requirements - General
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.
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Administrator/Licensee shall submit a plan on when this will be completed with results and/or provide previous results for staff by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on:LPA did not observe TB results for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.
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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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2023


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Document Has Been Signed on 12/10/2023 03:07 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/10/2023 at 01:53 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: 12/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2023
Section Cited
CCR
87470(c)

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Infection Control Requirements
An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.
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Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on: LPA inquired with both staff regarding the Infection Control Plan. LPA did not receive an answer from either.This violation poses an immediate health, and safety risk to residents in care.
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Type A
12/11/2023
Section Cited
CCR87465(h)(2)

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Incidental Medical and Dental Care
The following requirements shall apply to medications which are centrally stored:
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.
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Administrator/Licensee shall submit a plan to conduct an in-service on medication management with all staff. In addition, proof of completion shall be submitted with signatures and dates by fax on POC due date.
Plan -12/11/23
Inservice due -12/18/23 additional time to be requested in writing to CCL.
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This requirement is not met as evidenced by: Based on: LPA observed medications belonging to staff accessible and on top of refrigerator not locked.This violation poses an immediate health, and safety risk to residents in care.
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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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2023


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Document Has Been Signed on 12/10/2023 03:07 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/10/2023 at 02:07 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: 12/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2023
Section Cited
HSC
1569.618(c)(3)

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(3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
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Administrator/Licensee shall submit a plan when training for staff has been set which is to be faxed on POC due date.
Plan -12/11/23
Additional time to be requested in writing to CCL.
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This requirement is not met as evidenced by: Based on: LPA did not observe current first aid/CPR certificates for staff during this visit. This violation poses an immediate health, and safety risk to residents in care.
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Type B
12/11/2023
Section Cited
CCR87506(a)

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Resident Records
The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff
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Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on: LPA observed records of residents incomplete, without signatures and dates. This violation poses a potential health, and safety risk to residents in care.
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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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2023


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Document Has Been Signed on 12/10/2023 03:07 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/10/2023 at 02:13 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: 12/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/11/2023
Section Cited
CCR
87303(c)

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Maintenance and Operation
All window screens shall be clean and maintained in good repair.
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Administrator/Licensee shall submit a plan on when this will be completed by fax on POC due date.
12/11/23
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This requirement is not met as evidenced by: Based on: LPA observed screen at front of facility window to be not in good repair. This violation poses a potential health, and safety risk to residents in care.
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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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2023


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