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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600383
Report Date: 12/23/2023
Date Signed: 12/23/2023 05:19:57 PM

Document Has Been Signed on 12/23/2023 05:19 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:
12/23/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Michelle PerezTIME COMPLETED:
05:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced on 12/23/23 at 3:30pm to conduct a Case Management - Deficiencies visit. LPA met with Caregiver(s) Michelle Perez and Elvis Perez and stated the purpose of the visit. Michelle Perez, Caregiver was unable to contact Arlene Gomez, Administrator regarding todays visit. Michelle stated that Arlene Gomez submitted a plan of correction to the Community Care Licensing Office.

Observations during this visit regarding Deficiencies that were cited on 12/10/23:
-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 for neither. Michelle Perez, Caregiver stated that the file has not been updated with pertinent documentation or proof of payment to renew. She also stated Arlene Gomez has not received the renewal yet. NOT CLEARED TO BE RE-CITED
-LPA did not observed an updated LIC308 Designation of Responsibility NOT CLEARED TO BE RE-CITED
-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. Michelle stated it was ordered and it has not been delivered yet. NOT CLEARED TO BE RE-CITED
-LPA did not observe TB results for staff. Michelle stated regarding the TB for staff Arlene Gomez is working on it. NOT CLEARED TO BE RE-CITED
-LPA inquired with both staff regarding the Infection Control Plan. Michelle has not received a copy of the Infection Control Plan. NOT CLEARED TO BE RE-CITED
-LPA observed medications belonging to staff accessible and on top of refrigerator not locked. - LPA observed the same medications on top of the refrigerator which was removed during this visit. A photo was taken. NOT CLEARED TO BE RE-CITED
- During file review LPA observed expired first aid/CPR certificates for staff. Michelle stated regarding the First Aid/CPR for staff Arlene Gomez is working on it. NOT CLEARED TO BE RE-CITED

See 809C for continuation...
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2023
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: 12/23/2023
NARRATIVE
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809 Continued...

-LPA observed screen at front of facility window to be not in good repair. LPA observed the window screen has not been repaired. A photo taken. NOT CLEARED TO BE RE-CITED

-LPA observed records of residents (R) incomplete, without signatures and dates. A review of R1 and R2 files during this visit revealed the files have not been corrected. NOT CLEARED TO BE RE-CITED

The Department is not in receipt of the Plan of Correction that was submitted by the Administrator Arlene Gomez and proof was not provided during this visit. LPA shall issue an Advisory note. In addition, the Licensee/Administrator shall submit the documents requested below.

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 re-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 facility representative 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: 12/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 12/23/2023 05:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/23/2023 at 04:34 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: 12/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2023
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.
12/24/23
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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
12/24/2023
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.
12/24/23
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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: 12/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2023


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 12/23/2023 05:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/23/2023 at 04:34 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: 12/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2023
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.
12/24/23
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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
12/24/2023
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.
12/24/23
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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: 12/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2023


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 12/23/2023 05:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/23/2023 at 04:35 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: 12/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2023
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.
12/24/23
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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
12/24/2023
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 -12/24/23
Inservice due -12/29/23 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: 12/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2023


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 12/23/2023 05:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/23/2023 at 04:35 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: 12/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2023
Section Cited
HSC
1569.618(c)(3)

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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 -12/24/23
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 A
12/24/2023
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.
12/24/23
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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: 12/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2023


LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 12/23/2023 05:19 PM - It Cannot Be Edited


Created By: Victoria Brown On 12/23/2023 at 04:35 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: 12/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/24/2023
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.
12/24/23
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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: 12/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/23/2023


LIC809 (FAS) - (06/04)
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