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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410504131
Report Date: 08/16/2024
Date Signed: 08/30/2024 01:23:30 PM

Document Has Been Signed on 08/30/2024 01:23 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:CATHOLIC CHARITIES ADULT DAY SERVICES-SAN MATEO COFACILITY NUMBER:
410504131
ADMINISTRATOR/
DIRECTOR:		CLEMENT-CIHAK, PATRICIAFACILITY TYPE:
775
ADDRESS:787 WALNUT STREETTELEPHONE:
(650) 592-9325
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 40CENSUS: 12DATE:
08/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Carmen Santoni, Program DirectorTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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 **This is an AMENDED report.**

On August 16, 2024, Licensing Program Analyst (LPA) John Calandra and Kiran Jain arrived at the facility at 8:30 AM to complete the Annual 1-year required inspection. LPA Calandra and John met with Program Director, Carmen Santoni and explained the purpose of the visit. Patty Clement, Associate Deputy Director joined the visit virtually over the phone.

LPAs Calandra and Jain toured the physical plant. This is a 1-story building with a kitchen, storage room, two staff offices, main activity room, and 3 bathrooms, and a courtyard. The facility's fire extinguishers were last checked on March 12, 2024 and were observed to be fully charged. No accessible bodies of water or hazards were observed in the courtyard. The facility's smoke detectors are directly connected to the San Carlos fire department per an interview with Carmen Santoni, Program Director. All food was observed to be in good condition.

Sharp objects were unlocked and accessible to persons in care. However, during the visit, Carmen Santoni, Program Director locked them in the presence of the LPAs.

A Type A Violation was provided for not having a Carbon Monoxide detector in the facility.

A Type A Violation was provided for having Disinfectants, cleaning solutions, poisons, and other items unlocked and accessible to persons in care.

A Type A Violation was provided for having water temperature exceeding 125 degrees Fahrenheit.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
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 08/16/2024 04:26 PM - It Cannot Be Edited


Created By: John Calandra On 08/16/2024 at 03:40 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: CATHOLIC CHARITIES ADULT DAY SERVICES-SAN MATEO CO
FACILITY NUMBER: 410504131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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HSC 1503.2: General Provisions: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 Carbon Monoxide detectors, which were missing from the facility and which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
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.
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 82087(a)(3): Buildings and Grounds: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bottles of Lysol and Bleach which were left unlocked and accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
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.
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
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/30/2024 01:25 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/19/2024 10:26 AM


Created By: John Calandra On 08/16/2024 at 03:40 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CATHOLIC CHARITIES ADULT DAY SERVICES-SAN MATEO CO
FACILITY NUMBER: 410504131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 82088(e)(1): Fixtures, Furniture, Equipment, and Supplies: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 bathrooms in which the water temperature exceeded 125 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
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
Administration
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/16/2024 04:26 PM - It Cannot Be Edited


Created By: John Calandra On 08/16/2024 at 03:40 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: CATHOLIC CHARITIES ADULT DAY SERVICES-SAN MATEO CO
FACILITY NUMBER: 410504131

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82075(m)
Health-Related Services
(m) Prescription medications which are not taken with the client upon termination of services, or which are not to be retained shall be destroyed by the administrator, or a designated substitute, and one other adult who is not a client.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 2 medication bottles which were unlocked and accessible to persons in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/17/2024
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
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2024


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: CATHOLIC CHARITIES ADULT DAY SERVICES-SAN MATEO CO
FACILITY NUMBER: 410504131
VISIT DATE: 08/16/2024
NARRATIVE
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A Type A Violation was provided for having medications unlocked and accessible to persons in care.

LPAs Calandra and Jain requested and received the following documents:

-Updated LIC 500
-Current Liability Insurance

LPAs Calandra and Jain reviewed 5 resident files and 4 staff files. All were observed to be complete.

LPAs Calandra and Jain interviewed 1 staff member and 1 resident.

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

An exit interview was conducted. This report was reviewed with Carmen Santoni, Program Director and a copy of the report along with Appeal Rights left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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