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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507207
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:21:42 PM

Document Has Been Signed on 03/22/2024 03:21 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:P.A.R.C.A. CEDAR STREET HOUSEFACILITY NUMBER:
410507207
ADMINISTRATOR:CARLETTE L PHIPPSFACILITY TYPE:
735
ADDRESS:721 CEDAR STREETTELEPHONE:
(650) 226-3798
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 8CENSUS: 7DATE:
03/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Chief Executive Officer (CEO), Diana ContiTIME COMPLETED:
03:30 PM
NARRATIVE
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On March 22, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Chief Executive Officer (CEO), Diana Conti, Interim Director of Program, Patrice Clay, Interim Director, Marites De La Cruz and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA toured four resident rooms, all of which were shared rooms. All resident rooms observed with all required furniture. LPA observed one staff/office room. Three full bathrooms were observed clean and odor-free; equipped with liquid soap, paper-towels, and non-skid mats. Hot water temperature throughout the facility measured between 113.7-116.4 degrees F. Extra linen was observed.

Living room and dining room was observed to be free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Sharps, toxins and medications were locked and inaccessible to residents. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of October 2023. LPA toured the kitchen and observed 2 days for perishables and 7 days non-perishables. Emergency drills are logged and done every every month.

LPA reviewed 5 client records and 5 staff records. During record review, LPA observed 3/5 client files with no signed admission agreement, 3/5 files did not have physician's reports, 5/5 did not have functional capabilities assessment. Based on staff records observed, 3/5 files reviewed did not have health screenings. During the visit, LPA discovered that 7 staff members were not associated to the facility. During the visit, Interim Director of Program provided LPA with required documents to associate individuals to the facility.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with the CEO, Interim Director of Program and Interim Director and a copy is provided with appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 03/22/2024 03:21 PM - It Cannot Be Edited


Created By: Komal Charitra On 03/22/2024 at 01:53 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: P.A.R.C.A. CEDAR STREET HOUSE
FACILITY NUMBER: 410507207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 5 client record reviewed, LPA observed 3/5 client files with no signed admission agreements.
POC Due Date: 03/29/2024
Plan of Correction
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Interim Director of Program indicated that all residents and responsible parties will be signing new admission agreements on 3/23/2024 and will notify LPA when its complete.
Type A
Section Cited
CCR
80019(f)
80019 Criminal Record Clearance: (f) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, LPA observed 7 staff members who were not associated to the facility, however had fingerprint clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/23/2024
Plan of Correction
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Facility provided LPA copies of LIC9182 for each staff member who are not associated with a copy of their DL during the visit. Deficiency is corrected.
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
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 03/22/2024 03:21 PM - It Cannot Be Edited


Created By: Komal Charitra On 03/22/2024 at 01:53 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: P.A.R.C.A. CEDAR STREET HOUSE
FACILITY NUMBER: 410507207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 5 personnel files reviewed, 3/5 staff members did not have health screening maintained in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee/administrator will have the 3/5 staff members who do not have health screenings in their files, go get a new health screening. In addition, licensee/administrator shall conduct an audit and ensure all staff have health screenings.
Type B
Section Cited
CCR
85068.2(b)(1)(F)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (F) The written functional capabilities assessment specified in Section 80069.2.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 5 client records reviewed, 5/5 files did not have a functional capabilities assessment in their files which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee/administrator will complete a new functional capabilities assessment for all clients and keep a copy in resident files.
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
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/22/2024 03:21 PM - It Cannot Be Edited


Created By: Komal Charitra On 03/22/2024 at 01:53 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: P.A.R.C.A. CEDAR STREET HOUSE
FACILITY NUMBER: 410507207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 5 clients record reviewed, the 3/5 client files did not have physician's reports which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee/administrator shall ensure all resident files have an updated and completed physician's report for all residents.
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:Cara Smith
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024


LIC809 (FAS) - (06/04)
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