385600397-11-4-2023-14-AS-APAA-CX9VV8-20231104164556

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600397
Report Date: 11/04/2023
Date Signed: 11/04/2023 04:46:11 PM

Document Has Been Signed on 11/04/2023 04:46 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 CARE HOME		FACILITY NUMBER:	385600397
ADMINISTRATOR:	ZHANG, ALICE FENG		FACILITY TYPE:	740
ADDRESS:	1434 7TH AVENUE		TELEPHONE:	(415) 516-9368
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY:	15	CENSUS: 13	DATE:	11/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Alice Feng Zhang		TIME COMPLETED:	05:15 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 11/04/2023, Licensing Program Analyst (LPA) Arielle Pascua arrived unannounced to conduct an annual visit. LPA met with Facility Designated Administrator (FDA) Alice Feng Zhang and explained the purpose of the visit. There were two other staff members present at this facility, Xiuqiong Liu and Teiai Wu. This facility is licensed to serve up to 15 elderly residents of which 2 may be non-ambulatory. Current Census was 13. A brief interview with FDA Zhang was conducted. LPA reviewed 4 resident files. 4 out 4 resident files were current and up to date. LPA reviewed 3 staff files. 3 out 2 staff files were current and up to date. The Administrator has a current administrator certificate #6021526740 and expires on 12/12/2023. A tour of the facility was conducted. A tour of the 9 resident bedrooms were conducted. Furniture and furnishings were observed to be present in 8 resident bedrooms. 1 out 9 resident bedrooms did not have a second chest of drawers to meet the resident's needs at this time. A tour of 3 bathrooms were conducted. Hot water temperature was taken to ensure Title 22 compliance at this time. Grab bars and skid mats were present and were in good repair. A tour of the kitchen was conducted. LPA observed a sufficient amount of 2 day perishable and 7 day nonperishable food supply at this time. A storage room was observed which housed additional non-perishable food supply. Knives were observed to be locked and made inaccessible at this time. A tour of the backyard was conducted. Perimeter fence and gates were observed to be in good repair. LPA observed a large pile of items such as cement blocks, varies pieces of wood, and other construction items. A tour of the laundry room was conducted. Laundry supplies such as detergent, toxins and other cleaning supplies were observed to be locked and made inaccessible to the residents in care.

SUPERVISOR'S NAME: Stephenie Doub	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Arielle Pascua	TELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023

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 CARE HOME	FACILITY NUMBER: 385600397
	VISIT DATE: 11/04/2023

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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 medication cabinet was located in the dining room was observed. Along with the FDA, the LPA reviewed and compared medication with medication dispensing logs. First aid kit was present.

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

Technical assistance is being provided today for the following section, 87465(h)(5).
A technical violation is being provided today for the following section, 87307(a)(3)(B) and 87303(a).

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: 11/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2023

LIC809 (FAS) - (06/04)

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