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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600397
Report Date: 01/03/2025
Date Signed: 01/03/2025 03:41:21 PM

Document Has Been Signed on 01/03/2025 03:41 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 HOMEFACILITY NUMBER:
385600397
ADMINISTRATOR/
DIRECTOR:
ZHANG, ALICE FENGFACILITY TYPE:
740
ADDRESS:1434 7TH AVENUETELEPHONE:
(415) 516-9368
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 15TOTAL ENROLLED CHILDREN: 0CENSUS: 14DATE:
01/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Alice Feng, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:55 PM
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On 1/3/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Alice Feng. The facility currently provides care for 14 residents, none of which are bedridden or receiving hospice services, or with a diagnosis of dementia.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the facility were found to be charged. Smoke detectors were present in each common room and resident bedroom with last fire safety inspection conducted in March 2024 ensuring all fire safety systems are in place. LPA was unable to determine if smoke alarms had interconnected carbon monoxide detectors. Administrator agrees to acquire and place a separate carbon monoxide detector in facility for safety measures. Technical Assistance issued.

There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. Cleaning supplies and other toxins are safely stored upon inspection. There was a supply of hygiene products and paper products available for residents. Resident's bedroom have lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. Upon spot review of medications, LPA found that the facility has documentation of resident prescriptions on file with medication counts in order.

Continued onto LIC809-C
Andrea MedlinTELEPHONE: (650) 266-8811
Dominic TobolaTELEPHONE: (650) 393-9128
DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/03/2025
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: 01/03/2025
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LPA conducted a sample file review for residents and found that 3 out of 4 residents had signed documentation indicating that the service plans had been reviewed and agreed upon by both residents and case managers. However, upon review of records, LPA found that the Administrator had not been provided copies of the actual service plans. LPA confirmed that the assessments had been completed and the Administrator will be contacting each resident case managers on acquiring the full documents. Technical Assistance issued. Upon a sample review of 4 staff files LPA found that all caregiver staff have current 1st aid and CPR certification and health screening reports on file.

During the visit, LPA and Administrator had discussed an incident that occurred approximately one month prior regarding a resident (R1) who had been sent out for medical check after staff observed R1 having difficulties ambulating. Administrator informed LPA of the changes observed in R1 during the past several months with no indications or statements from R1 of physical health concerns. LPA was informed that R1 is currently in the hospital and awaiting medical discharge. The Administrator immediately notified R1's case manager, conservator for mental health and R1's family. However, CCLD was not notified as Administrator explained the event was not a medical emergency or injury. LPA explained to Administrator the reporting requirements as the incident resulted in resident hospitalization. Administrator agrees to reconcile documentation by submitting an incident report of this event by POC date 1/4/2024. Technical Violation issued. Administrator has been in frequent contact with R1's case manager and has been visiting R1 in the medical center. R1 is currently receiving physical rehabilitation and awaiting discharge.

LPA requested the following documents be sent to CCL by COB 1/17/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 01/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025
LIC809 (FAS) - (06/04)
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