385601097-3-11-2021-14-AS-MHAN-BZ24AR-20210311175623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385601097
Report Date: 03/11/2021
Date Signed: 03/11/2021 05:57:05 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	SUTRO HEIGHTS CORPORATION		FACILITY NUMBER:	385601097
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	659 45TH STREET		TELEPHONE:	(650) 393-0265
CITY:	SAN FRANSISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	6	CENSUS: 13	DATE:	03/11/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Administrator, Juliet Pacaldo		TIME COMPLETED:	05:30 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 3/11/21 at 1:55pm, , Licensed Program Analyst (LPA), Murial Han and Licensed Program Analyst (LPA), Michael Garcia met with staff Helen Borja to conduct an unannounced tele-visit Pre-Licensing inspection for change of ownership via Zoom. Staff Helen Borja commenced virtual tour. Administrator, Juliet Pacaldo arrived shortly thereafter and tour resumed. There was 1 staff member (Federick Borja) present. Facility has approved fire clearance for 7 Ambulatory residents, 5 Non-Ambulatory residents and 2 Bedridden residents. Rooms were toured and the hot water temperature was measured in the bathroom sink was shown on the video with reading of 114.6 degrees F. The living room and the dining room are well maintained and appeared to be cleaned. The overall facility temperature was measured at 73 degrees F. The laundry room was cleaned and chemicals were locked. The medication storage area was locked and inaccessible to the residents. The Carbon Monoxide detectors were present and properly operated. The first aide kit was equipped. The refrigerator temperature was measured at 34 degrees F and the freezer was measured at -1 degree F with no expired foods identified. The chemical cabinet underneath the sink in the kitchen was observed to be broken and the left door can not lock properly. The Administrator stated that all the chemicals were removed and placed in the laundry chemical storage cabinet and it will be repaired this evening. The Activities Calendar, the Menu, the Resident Rights, the Licensing Complaint Poster and the Resident Council Rights are not posted. The Administrator stated that it will be posted by 3/15/2021 Continue on the next page......

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
	VISIT DATE: 03/11/2021

NARRATIVE

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There was no instructions on the water shut-off station and staff was not able to locate the utility and gas shut-off stations. The Administrator stated this will be corrected and education will be completed by 3/15/21

The Emergency Disaster supplies were not equipped. The Administrator stated that this will be corrected by 3/15/21.

The pathway to the garden is obstructed by debridements. The Administrator stated that everything will be cleared by 3/15/21

Pre-Licensing is incomplete with areas of concerns to be resolved by 3/15/2021.

Comp III orientation was given to the Administrator, Juliet Pacaldo on 3/11/21.

Exit interview conducted with the Administrator, Juliet Pacaldo. This report was reviewed and discussed with Ms. Pacaldo. An electronic copy of the report was emailed to the Administrator for signature.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2021

LIC809 (FAS) - (06/04)

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