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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410507269
Report Date: 02/09/2024
Date Signed: 02/09/2024 12:13:21 PM

Document Has Been Signed on 02/09/2024 12:13 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:CASSIA HOUSEFACILITY NUMBER:
410507269
ADMINISTRATOR:MARY BETH SANDOVALFACILITY TYPE:
735
ADDRESS:420 CASSIA STREETTELEPHONE:
(650) 363-8125
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 14CENSUS: 14DATE:
02/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Mary Beth SandovalTIME COMPLETED:
12:30 PM
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On February 9, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Mary Beth Sandoval and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. Facility operates on first and second level. The indoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. Outdoor and second floor exit route passageway was observed. Exit route passageways observed had chairs and a coffee table blocking the exit route.

There are seven shared client bedrooms, four common bathrooms, dining room, kitchen, activity room, laundry room, storage areas and offices. Client bedrooms were observed to have all required furniture. Bathrooms were clean and odor-free; equipped with soap and toilet paper. LPA checked the first aid kit and food supplies. 2 day perishables and 7 day non-perishable food were present. Sharps, toxins and medications were locked and inaccessible to clients in care. Water temperature throughout the facility measured between 106.8-137 degrees F. Men's bathroom on the second floor measured at 137 degrees F and staff bathroom on the first floor measured at 134.7 degrees F. Administrator printed out hot water caution signs and posted them in the men's and staff bathroom. Extra linen was observed to be present.

A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of August 2023. Emergency drills are logged and done every month. LPA reviewed 5 client records and 5 staff records. Client records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 02/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/09/2024
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 02/09/2024 12:13 PM - It Cannot Be Edited


Created By: Komal Charitra On 02/09/2024 at 11:59 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: CASSIA HOUSE
FACILITY NUMBER: 410507269

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients 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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Based on observations, 2/4 bathroom water temperatures measured above 120 degrees F. The first floor staff bathroom water temperature measured at 134.7 degrees F and the second floor men's bathroom water temperature measured at 137 degrees F which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/16/2024
Plan of Correction
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Deficiency was corrected during the visit. Administrator posted hot water caution signs in both bathrooms.
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: 02/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2024


LIC809 (FAS) - (06/04)
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