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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507207
Report Date: 02/08/2024
Date Signed: 02/08/2024 11:46:45 AM

Document Has Been Signed on 02/08/2024 11:46 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: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:
02/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Caregiver, Carmelita De CastroTIME COMPLETED:
12:00 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 February 8, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to complaint control #: 14-AS-20240112093523. LPA met with Caregiver, Carmelita De Castro and explained the purpose of the visit.

During the complaint visit, LPA discovered that there were no personnel files present in the facility to provide to LPA for review. In addition, during file review, LPA discovered Client 1's (R1's) file did not have an individualized service plan.

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 Caregiver and a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2024
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 2
Document Has Been Signed on 02/08/2024 11:46 AM - It Cannot Be Edited


Created By: Komal Charitra On 02/08/2024 at 10:59 AM
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: 02/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
80066(c)

1
2
3
4
5
6
7
80066 Personnel Records:
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. removal of records shall be subject to the following requirements:

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/administrator shall ensure personnel files for all current and previous staff is maintained on the facility premises with all required documents as specified in CCR80066.
8
9
10
11
12
13
14
Based on observations, administrator was unable to provide LPA any personnel files to review.
8
9
10
11
12
13
14
Type A
02/09/2024
Section Cited
CCR85068.2(b)

1
2
3
4
5
6
7
85068.2 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:

Violation of this regulation is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/administrator shall complete a written Needs and Services Plan for R1 to include all information specified on CCR 85068.2. A copy shall be submitted to LPA by 2/9/2024.
8
9
10
11
12
13
14
Based on R1's file reviewed, LPA did not observe a copy of R1's needs and service plan
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: 02/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/08/2024


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