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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601097
Report Date: 07/25/2024
Date Signed: 07/25/2024 06:58:37 PM


Document Has Been Signed on 07/25/2024 06:58 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:SUTRO HEIGHTS CORPORATIONFACILITY NUMBER:
385601097
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:659 45TH STREETTELEPHONE:
(415) 571-8531
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94121
CAPACITY:14CENSUS: 8DATE:
07/25/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Shirley Aguado and Julio YapTIME COMPLETED:
07:00 PM
NARRATIVE
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During complaint investigation--which included review of medication administration procedures and staff training--deficiencies of the following California Code of Regulations, Title 22/Health and Safety Code are observed. Citations appear on a following page.

Civil penalty of $100 is issued for violation of Criminal Record Clearance.

Per Health and Safety Code 1569.69, in facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete 8 hours of in-service training on medication-related issues in each succeeding 12-month period.

Citation appears on a following page.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
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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Document Has Been Signed on 07/25/2024 06:58 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SUTRO HEIGHTS CORPORATION
FACILITY NUMBER: 385601097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2024
Section Cited
CCR
87355

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 CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility obtain a CA clearance or a criminal record exemption as required by the Department.
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Staff RC must obtain Criminal Record Clearance to continue to have client contact. Plan/proof of correction to be submitted to CCLD BY DUE DATE.
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This requirement is not met, as staff RC is working with clientsfor over 30 days and does not yet have criminal record clearance. He was fingerprinted but not yet clieared. Licensee failed to ensure that staff working with clients have criminal record clearance, which poses an immediate health, safety or personal rights risk.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/25/2024 06:58 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SUTRO HEIGHTS CORPORATION
FACILITY NUMBER: 385601097

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/08/2024
Section Cited
HSC
1569.69

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HEALTH AND SAFETY CODE
Each RCFE... shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the... training requirements listed on page one of this report.
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Proof of required medications training for staff SA and JQ will be sent to CCLD BY DUE DATE
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This requirement was not met, as staff who handle medications--including giving pre-poured medications to clients--have not received required medications training. Licensee failed to ensure that required medications training is given to staff who handle clients' medications, which poses a potential health, safety or personal rights risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3