385600396-10-22-2023-14-AS-APAA-CWUW32-20231022165510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600396
Report Date: 10/21/2023
Date Signed: 10/22/2023 04:55:28 PM

Document Has Been Signed on 10/22/2023 04:55 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:	SUNSET GARDENS		FACILITY NUMBER:	385600396
ADMINISTRATOR:	EISEMAN, KATIE		FACILITY TYPE:	740
ADDRESS:	1338 27TH AVENUE		TELEPHONE:	(650) 219-9645
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	13	CENSUS: 10	DATE:	10/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Katie Eiseman		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/21/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to this facility unannounced to conduct an annual visit. LPA was met by staff member (SM), Geselle Grey and explained the purpose of the visit. LPA Pascua asked SM Grey to go ahead and call the Facility Designated Administrator, Katie Eiseman and inform them that CCL was present at this time. FDA Eiseman informed LPA Pascua that she would meet the LPA at the facility in about 30 minutes and to continue the visit with SM Grey. There was one other staff member present at this time, Elizabeth Celso. This facility is licensed to serve and retain 13 residents who are 60 and over. Of the 13, six (6), may be non-ambulatory in bedrooms 1,2,3 and 6. This facility also has a dementia plan on file and a hospice waiver for 4. LPA reviewed 5 resident files and 3 staff files. 3 out of 3 staff files were complete and updated. 5 out 5 resident files did not have an updated Reappraisal conducted. The Facility Designated Administrator current holds an active administrator certificate, #6024255740 and expires on 04/07/2024. A tour of the facility was conducted. This facility has 2 floors with 4 bedrooms on the first floor and 3 on the second floor. Fire extinguishers located throughout the facility were last serviced on 02/22/2023 by the local Fire company, fire shield. A tour of the first floor was conducted. A tour of the resident bedrooms were conducted. Furniture and furnishings were observed to be maintained and in good repair. Two resident bathrooms were toured are conducted, hot water temperature was taken to ensure it was between 105-120 degrees. A tour of the garage was conducted. Additional perishable and non-perishable food supply was identified. A linen closet was identified and was observed to have a sufficient amount of linen to meet the residents needs. A tour of the laundry room was conducted. Detergent, cleaning supplies, and other toxins were observed to be locked and made inaccessible. Washer and dryer were observed to be in working condition.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

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: SUNSET GARDENS	FACILITY NUMBER: 385600396
	VISIT DATE: 10/21/2023

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A tour of the 2nd floor was conducted.
Evacuation chair was observed to be in a closet next to the stairs.
This floor holds 3 resident bedrooms and 1 1/2 bathrooms. A tour of the resident bedrooms were conducted. Furniture and furnishings were observed to be in compliance and meet the residents needs.
Hot water temperature was taken to ensure compliance with regulatory temperature of 105-120.
A tour of the dining room, living room, and other areas intended for resident use were conducted. Furniture and furnishing were observed to meet the resident's needs.
A tour of the kitchen was conducted. LPA observed a sufficient amount of 2-day perishable and 7 day non perishable food supply.
A medication cabinet was located near the half bathroom. Along with the FDA, the LPA reviewed and compared medication with medication dispensing logs. First aid kit was present.
A tour of the yard was conducted with no hazards present. An office was identified and a ramp leading to the facilities sunroom was also identified. Perimeter gates and fence was observed to be stable and in good repair.

The following documents were requested to updated and sent to CCL:
-LIC 308
-LIC 309
-LIC 400
-LIC 500
-LIC 610

Technical assistance is being provided today for the following section, 87463(d).

Based on the observations made during this visit no deficiencies were observed or cited during this annual visit. An exit interview was conducted and a copy of this report was given to Facility Designated Administrator.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2023

LIC809 (FAS) - (06/04)

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