<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507207
Report Date: 01/04/2024
Date Signed: 01/04/2024 12:54:40 PM

Document Has Been Signed on 01/04/2024 12:54 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:DANIELLE SANCHEZFACILITY TYPE:
735
ADDRESS:721 CEDAR STREETTELEPHONE:
(650) 226-3798
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY: 8CENSUS: DATE:
01/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Caregiver, Carmelita De CastroTIME 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 January 4, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an attempted unannounced case-management visit in relation to an incident report that was sent to CCL on 11/15/2023. LPA met with Caregiver, Carmelita De Castro and explained the purpose of the visit.

On 11/15/2023, the Licensee reported that staff members reported to the CEO, Diana Conti on 9/17/2023 that Staff 1 (S1) does not feed clients enough food, verbally abused a client (R1) and made R1 scrub the bathroom floor with a brush. In addition, it was indicated that the medication cabinet had been broken for awhile.

During the visit, LPA toured the facility with the Caregiver. LPA observed medication to be locked an inaccessible to clients . LPA observed sufficient food supply, however did not observe a food menu. According to the Caregiver, the facility cooks what the clients' request.

The incident initially occurred on 9/17/2023 when staff members notified Diana Conti of this error, however facility failed to report the incident to CCL until 11/15/2023. In addition, the facility failed to ensure a menu is written at least one week in advance and copies are kept on file for review by clients.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiencies may result in Civil Penalties.

Report is reviewed with Caregiver, Carmelita De Castro and a copy is provided with appeal rights. Further investigation is required regarding this incident.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2023
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 2
Document Has Been Signed on 01/04/2024 12:54 PM - It Cannot Be Edited


Created By: Komal Charitra On 01/04/2024 at 12:12 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: 01/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/11/2024
Section Cited
CCR
80061(b)

1
2
3
4
5
6
7
80061 Reporting Requirements: (b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event...

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Administrator/Licensee shall review CCR 80061 and submit acknowdgement to LPA by 1/11/2024. Administrator/Licensee shall conduct an in-service training with staff regarding reporting requirements
8
9
10
11
12
13
14
Based on records reviewed, the facility had an incident on 9/17/2023, however did not report to CCL until 11/15/2023. The facility failed to submit a written report within seven days following the incident.
8
9
10
11
12
13
14
Type B
01/11/2024
Section Cited
CCR80076(a)(5)

1
2
3
4
5
6
7
80076 Food Services: (a) In facilities providing meals to clients, the following shall apply: ( 5) Menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file for at least 30 days. Menus shall be made available for review by the clients or their authorized representatives and the licensing agency upon request.

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator to submit a copy of the facility's food menu that meets CCR 80076 Food Service regulation. Licensee/Administrator shall submit a written plan in writing on how to ensure weekly/monthly menus are posted for clients
8
9
10
11
12
13
14
Based on observations and interviews, LPA did not observe a food menu posted at the facility. According to the Caregiver, the administrator is working on a menu and the facility provides preferred meals to clients
8
9
10
11
12
13
14
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: 01/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024


LIC809 (FAS) - (06/04)
Page: 2 of 2