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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600385
Report Date: 06/02/2023
Date Signed: 06/14/2023 10:27:39 AM


Document Has Been Signed on 06/14/2023 10:27 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/13/2023 10:38 AM

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

NARRATIVE
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On June 14, 2023, Licensing Program Analysts (LPA) Komal Charitra and Murial Han conducted an unannounced visit to deliver a copy of an amended 809D report that was provided on June 2, 2023. LPA met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit.

On June 2, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced health and safety case-management visit. LPA met with Licensee/Administrator, William Encarnacion and explained the purpose of the visit.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a two story facility. LPA observed living room and dining room on the first floor to be clean and odor-free. A comfortable temperature is maintained and lighting is sufficient for comfort. During the visit, LPA observed two residents watching television in the living room and two staff members were present. LPA observed one shared resident room with beds 6ft apart from each-other and two staff rooms on the first floor. Communal bathroom was observed to be clean. LPA advised Licensee to replace bar soaps with liquid soap and ensure paper-towels were present in the bathroom. Shower was equipped with non-skid mats.

LPA toured the kitchen and observed low food supply, however Licensee indicated he has planned to go to the grocery store this afternoon. LPA observed toxins, chemicals, and sharps to be unlocked and accessible to residents in care. Licensee immediately locked sharps and toxins in LPAs presence. Medication cabinet was observed to be locked and inaccessible. First aid kit was observed to be present. LPA advised Licensee to replace hand-towels with paper-towels in kitchen.

LPA toured the downstairs of the facility. LPA observed two residents rooms; one private room and one shared room with beds 6ft apart. LPA observed a communal bathroom to be equipped with liquid soap. LPA advised Licensee to ensure paper-towels are present and bar soaps are removed. LPA observed a resident in the communal living room downstairs sitting down. (continue to 809C)
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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 3


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
VISIT DATE: 06/02/2023
NARRATIVE
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LPA observed washer and dryer in good repair and extra linen was observed to be present. Detergent and cleaning solution was observed to be unlocked. LPA observed one storage room with facility's belongings. LPA observed garage to be locked. LPA observed garage room to have an added section to include a staff sleeping area.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Licensee and a copy is provided with appeal rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 06/14/2023 10:28 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/13/2023 10:41 AM

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: 06/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2023
Section Cited
CCR
87309(a)

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

Violation of this regulation is not met as evidenced by:
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Licensee immediately locked chemicals, toxins and sharps in the kitchen in LPAs presence.

Licensee to submit a photo of locked cabinet downstairs with cleaning solutions and detergent.
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Based on observations, LPA observed chemicals, toxins and sharps in the kitchen to be unlocked an accessible to residents. In addition, LPA observed cleaning solution and detergent downstairs to be unlocked and accessible.
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Licensee to submit photos of locked cabinets by 6/3/23.

Licensee to conduct in-service with staff by 6/5/23 in relation to the importance of locking chemicals, sharps, and toxins.
Type A
06/09/2023
Section Cited
CCR87307(a)(2)(B)

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87307 Personal Accommodations and Services:
(a) ...The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. (2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements...(B) No room commonly used for other purposes shall be used as a sleeping room for any resident. This includes any hall, stairway, unfinished attic, garage storage area, shed or similar detached building.
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Licensee to submit LPA a floor plan to submit to the Fire Department for a new fire clearance.

Licensee to submit a written plan in writing describing how to meet CCR 87307.
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Violation of this regulation is not met as evidenced by: Based on observations, LPA observed a bed in the garage. According to the Licensee, one of the staff members it utlizing the garage as a staff sleeping area.
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*AMENDED* Licensee to submit a new written plan in writing to address how to provide habitable living accomodations for staff until proper fire clearance has been obtained
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
LIC809 (FAS) - (06/04)
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