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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 09/14/2022
Date Signed: 09/14/2022 05:33:40 PM


Document Has Been Signed on 09/14/2022 05:33 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CORINTHIAN GARDEN RESIDENTIAL CARE HOMEFACILITY NUMBER:
385600385
ADMINISTRATOR:ENCARNACION, WILLIAM S.FACILITY TYPE:
740
ADDRESS:170 APTOS AVENUETELEPHONE:
(415) 841-0311
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94127
CAPACITY:6CENSUS: 5DATE:
09/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Caregiver, Juanita SalvievoTIME COMPLETED:
01:10 PM
NARRATIVE
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On 9/14/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Juanita Salvievo and LPA explained the purpose of today's visit.

LPA toured facility and grounds. LPA observed signs posted by the front door and through-out the facility. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with soap and paper towels, and hand washing instruction is posted. Trash cans are observed to have foot operated lids.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kits are inspected and complete.

Based on documents provided, LPA observed the last COVID-19 screening for residents and staff was completed on April 22 ,2022. According to staff, facility stopped conducting the daily COVID-19 for staff and residents as of April 23, 2022.

Based on observation, record review and interview, the facility did not continue with the daily COVID-19 screening, this deficient is cited under California Code of Regulations, Title, 22 cited LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the caregiver and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
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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Document Has Been Signed on 09/14/2022 05:33 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CORINTHIAN GARDEN RESIDENTIAL CARE HOME
FACILITY NUMBER: 385600385

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/14/2022

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
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Based on observation, interview, and record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal - as the facility stopped conducting the last daily COVID-19 screening as of April 23,2022.
POC Due Date: 09/21/2022
Plan of Correction
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The administrator will review the latest CCLD Provider Information Notices (PIN) on COVID-19 and resume the daily COVID-19 screening for residents and staff immediately. The administrator will provide in-service to staff on the importance of the daily COVID-19 screening and submit a copy of the in-service sign-in sheet along with a copy of the daily staff and resident's COVID-19 screening to CCL by the plan of correction due date 9/21/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/14/2022
LIC809 (FAS) - (06/04)
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