410506298-8-1-2022-14-AS-KCHA-CGVNGT-20220801102736

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410506298
Report Date: 08/01/2022
Date Signed: 08/01/2022 10:27:50 AM

Document Has Been Signed on 08/01/2022 10:27 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ANGELA'S REST HOME I		FACILITY NUMBER:	410506298
ADMINISTRATOR:	ANA MANE AREVALO		FACILITY TYPE:	740
ADDRESS:	1816 LOUVAINE DRIVE		TELEPHONE:	(650) 992-1690
CITY:	COLMA	STATE: CA	ZIP CODE:	94015
CAPACITY:	6	CENSUS: 4	DATE:	08/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Administrator, Ana Marie Arevalo		TIME COMPLETED:	10:35 AM

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 August 1, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID-19 signage posted on the front door. LPA met with Caregiver, Teddy Geonanga and Administrator, Ana Marie Arevalo joined shortly thereafter. Administrator screened LPA and was able to provide LPA with screening log documentation for residents, staff, and visitors. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed two staff members during the visit without a face covering. This is a single story home with 2 resident bedrooms, 1 staff bedroom, and 2 full bathrooms. LPA observed both resident bedrooms to be shared rooms with beds 6ft apart. LPA observed the bathrooms to be equipped with liquid soap, paper towels, and a covered trash bin. LPA advised Administrator to post hand-washing signs in both bathrooms. Infection control practices are observed: COVID-19 signage posted throughout the facility, 30 day PPE supply, and resident/ visitors/ and staff daily monitoring records. LPA observed medications, sharps, and toxins locked and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable present. In addition LPA observed the extra food supply in the garage. A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. First aid kit was observed to be present and completed. First aid cards were observed to be current. LPA toured the garage and observed washer and dryer to be in good working condition. Extra linen was observed to be present. CONT. to 809C

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

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: ANGELA'S REST HOME I	FACILITY NUMBER: 410506298
	VISIT DATE: 08/01/2022

NARRATIVE

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It was found during the visit that an individual (S1) was not associated to the facility. LPA reviewed the staff roster with the Administrator and confirmed that S1 is not associated to the facility but does have a fingerprint clearance.

This violation results in a civil penalty of $100 per day x 5 days = $500.00.

LPA requests the following forms to be submitted to CCLD by 8/8/22:

LIC308 Designation of Administrative Responsibility
LIC500 Personnel Report
LIC610E Emergency Disaster Plan

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with Administrator, and a copy is provided with appeal rights.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/01/2022 10:27 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ANGELA'S REST HOME I	FACILITY NUMBER: 410506298
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87468.1(a)(2)

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as staff were observed to not have a face mask on which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/02/2022
	Plan of Correction
1 2 3 4	Facility administrator to conduct an in-service training with staff regarding the importance of wearing a face mask around residents and other staff members.

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance (e) 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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, licensee failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. Immediate civil penalty of $500 was issued today. $100 x 5 days = $500.00
	POC Due Date: 08/02/2022
	Plan of Correction
1 2 3 4	Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. In addition, Administrator will submit 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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2022

LIC809 (FAS) - (06/04)

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