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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600421
Report Date: 01/05/2024
Date Signed: 02/06/2024 10:38:45 AM

Document Has Been Signed on 02/06/2024 10:38 AM - 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:CAYCO'S CARE HOMEFACILITY NUMBER:
385600421
ADMINISTRATOR:CAYCO, MARIBEL GFACILITY TYPE:
740
ADDRESS:1855 35TH AVENUETELEPHONE:
(415) 665-9409
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94122
CAPACITY: 6CENSUS: 5DATE:
01/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Rodella Pasamonte and Jude Torres, CaregiversTIME COMPLETED:
03:30 PM
NARRATIVE
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On January 5, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:06 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Rodella Pasamonte and Jude Torres, Caregivers. Administrator, Maribel Cayco joined later in the visit.

LPA Calandra toured the physical plant. This is a two story building that consists of 5 bedrooms(4 for residents and 1 staff bedroom) and 2 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguisher in the facility was observed to be fully charged. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen and garage refrigerators and freezers temperature were within the required range. All bedrooms were sufficiently lit and had the required furniture. The front and backyards were clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. The facility does not handle any cash resources. There were 3 staff and 4 residents present during the inspection.

All knives and sharp objects were observed to be locked and in-accessible to persons in care.

All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA Calandra reviewed 5 resident records. Four of the records did not contain a Needs and Services Plan and one did not have an LIC 602: Physician's Report.

LPA also reviewed 3 resident records. All were observed to be complete.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 3 of 9
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: CAYCO'S CARE HOME
FACILITY NUMBER: 385600421
VISIT DATE: 01/05/2024
NARRATIVE
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LPA interviewed 2 residents and 2 staff.

Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties.

A copy of the Report, Citation, and Technical Violation was reviewed with Administrator/Licensee, Mirabel Cayco and left at the facility. Appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 02/06/2024 10:38 AM - It Cannot Be Edited


Created By: John Calandra On 01/05/2024 at 02:43 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAYCO'S CARE HOME
FACILITY NUMBER: 385600421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(a)(1)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (1) Evacuation procedures, including identification of an assembly point or points that shall be included in the facility sketch.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview with Caregiver, Jude Torres, the licensee did not comply with the section cited above in 1 out of 1 instances, as the facility does not currently have a facility sketch identifying evacuation procedures, including identification of an assembly point or points which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/07/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Section Cited
Other Provisions
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
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:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/06/2024 10:38 AM - It Cannot Be Edited


Created By: John Calandra On 01/05/2024 at 02:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CAYCO'S CARE HOME
FACILITY NUMBER: 385600421

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(e)(2)
HSC 1569.695(e)(2): A facility shall have all fo the following information readily available to facility staff during an emergency:

(2) Anappraisal of resident needs and services plan for each resident.

This requirement is not met as evidenced by review of 5 resident records, 4 of which did not contain the resident's needs and services plan.
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 out of 5 resident files in which no needs and services plan was present, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee/Administrator to submit written needs and services plans by end of day on Friday, January 12, 2024.
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:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024


LIC809 (FAS) - (06/04)
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