385601097-2-8-2023-14-AS-MHAN-CNUSCR-20230208124558

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385601097
Report Date: 02/08/2023
Date Signed: 02/08/2023 04:42:17 PM

Document Has Been Signed on 02/08/2023 04:42 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
SF COASTAL AC/SC, 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:	(415) 571-8531
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94121
CAPACITY:	14	CENSUS: 12	DATE:	02/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Manager, Oscar Madrigal		TIME COMPLETED:	01:00 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 2/8/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by manager, Oscar Madrigal. LPA explained the purpose of the visit and LPA was screened at the front entrance. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. there are 12 residents at the facility and the beds in the shared rooms are observed to be 6" apart. There are 4 staff and manager on duty during the visit. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations. Trash cans are recommended to have foot operated lids. Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete. There are 6 residents, and 1 staff member ( the other staff is on break) present during the inspection. During today's tour at 10:15AM, LPA observed resident #1(R1) and resident #2(R2)'s room to be uncleaned and unsanitary. LPA observed several spider webs and one with a spider on it around the window by R2, dust and many dead ants on the baseboard behind R2's bed and soiled tissue paper on the floor next to R2's bed. In addition, LPA observed black particles in R1's drawer, shape appears to be similar to mouse droppings.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
	VISIT DATE: 02/08/2023

NARRATIVE

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According to R1 and R2, there is an ant infestation in their room and it was reported to the administrator.

LPA shared the observation with manager who instructed staff to clean the room immediately.

Based on observation, deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed with manager.

A copy of this report and appeal rights are provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/08/2023 04:42 PM - 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SUTRO HEIGHTS CORPORATION	FACILITY NUMBER: 385601097
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by: during the facility tour, LPA observed spider webs, dead ants, mouse droppings in R1 and R2's room
	Deficient Practice Statement
1 2 3 4	Based on observation, and interview, the licensee did not comply with the section cited above as the facility failed to ensure resident's room is cleaned, safe and sanitary which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/09/2023
	Plan of Correction
1 2 3 4	The licensee will develop a plan to ensure resident rooms are clean, sanitary and safe at all times. This plan needs to include the steps that the facility will take to ensure compliance. In addition, the licensee will provide in-service to staff of such plan. The licensee will provide a copy of the plan and a copy of the staff in-service sign-in record to CCL by 2/9/2023.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC809 (FAS) - (06/04)

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