385600421-10-24-2024-14-AS-DTOA-DACQ3Y-20241024114931

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600421
Report Date: 10/24/2024
Date Signed: 10/24/2024 11:49:47 AM

Document Has Been Signed on 10/24/2024 11:49 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 HOME		FACILITY NUMBER:	385600421
ADMINISTRATOR/ DIRECTOR:	CAYCO, MARIBEL G		FACILITY TYPE:	740
ADDRESS:	1855 35TH AVENUE		TELEPHONE:	(415) 665-9409
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:48 AM
MET WITH:	Jude Torres, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	12:00 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 10/24/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver, Jude Torres. Licensee/Administrator, Maribel Cayco was contacted and informed of the visit but unable to attend due to being out of the country. The facility currently provides care for 5 residents, none of which are receiving hospice services and some of which 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 in kitchen and garage were found to be charged. Smoke and carbon monoxide detectors located throughout the facility were in working order. There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Sharps stored under the kitchen sink and cleaning supplies stored in the bathroom were found to be secured. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items.There is a single outdoor patio for resident use with shading. Exits are also equipped with motion sensors with auditory alarms signaling to the staff common area. Continued onto LIC809-C

Andrea Medlin	TELEPHONE: (650) 266-8811
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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: CAYCO'S CARE HOME	FACILITY NUMBER: 385600421
	VISIT DATE: 10/24/2024

NARRATIVE

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LPA conducted a sample file review for residents and found that one (1) resident (R1) with a primary diagnosis of dementia is in need of an updated physician's report. In addition, a technical violation was issued for a resident (R2) that was newly admitted on 9/3/2024, in need of a full medical assessment prior to admission. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and onboard records on file. Lastly, A spot check of medications was conducted and found that all medication counts and records to be in order.

Maribel Cayco's Administrator Certificate, 7011093740 is currently on the department pending list for renewal as of 7/17/2024.

LPA requested the following documents be sent to CCL by COB 11/7/2024:

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

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/24/2024 11:49 AM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 resident with a diagnosis of dementia in need of an updated medical assessment, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	Licensee agrees to submit an updated medical assessment/physicain's report to CCLD for resident (R1) by POC date 11/7/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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