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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
410508446
Report Date:
11/03/2023
Date Signed:
11/03/2023 01:33:55 PM
Document Has Been Signed on
11/03/2023 01:33 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
ADMINISTRATOR:
GALATI, IDA
FACILITY TYPE:
740
ADDRESS:
1640 ELEANOR DRIVE
TELEPHONE:
(650) 315-2114
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94402
CAPACITY:
6
CENSUS:
4
DATE:
11/03/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:20 AM
MET WITH:
Administrator, Ida Galati
TIME COMPLETED:
01:45 PM
NARRATIVE
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On November 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Ida Galati 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 observed. Outdoor passageways was observed to have furniture. No accessible bodies of water of fire safety hazards observed. Two staff rooms were observed. Resident rooms were observed to be equipped with required furnishings and bathrooms were observed to be clean and odor-free. Water temperature throughout the facility measured at 85.1-95.7 degrees F. A comfortable temperature of 69 degrees F is maintained and lighting is sufficient for comfort. Door alarms were observed to be off and not working.
Sharps and toxins were observed to be unlocked and accessible to residents. Medication cabinet was observed to be locked. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of November 2022. LPA observed 2 days for perishables and 7 days non-perishables. LPA observed expired milk in the refrigerator and opened bottles of mayonnaise and mustard in the kitchen pantry. Emergency drills were not observed. According to Administrator, drills are conducted every month, however she was unable to locate the training logs.
LPA reviewed 4 resident records and 3 staff records. Based on record reviews: 3/4 residents did not have an updated physician's report and 4/4 files did not have a needs and service plan. Based on 3/3 staff records reviewed, staff records were observed to be complete, however training logs were not provided by the administrator.
Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in additional civil penalties. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
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
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, cabinet with chemicals and toxins were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/04/2023
Plan of Correction
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3
4
Administrator immediately locked the chemicals and toxins in LPAs presence. Deficiency is corrected and cleared.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observations, LPA observed an expired gallon of milk in the fridge. In addition, LPA observed open bottles of mayonnaise and mustard in the kitchen pantry.
POC Due Date:
11/04/2023
Plan of Correction
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Administrator immediately threw out the expired milk and stored the open bottles of mayonnaise and mustard in the fridge in LPAs presence. Deficiency is cleared and 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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observations, LPA observed sharps unlocked and ccessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/04/2023
Plan of Correction
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2
3
4
Administrator immediately locked knives in a cabinet in LPAs presence. Deficiency is cleared and corrected.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, door alarms on resident doors; from resident rooms to outdoor passageways were observed to be off which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/04/2023
Plan of Correction
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Administrator turned all alarms on in LPAs presence. Administrator to conduct an in-service training with staff to ensure all door alarms are on at all times.
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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(12)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (12) The Infection Control Plan pursuant to Section 87470.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, Administrator acknowledged the facility did not have an infection control plan which poses a potential health and safety risk for residents in care.
POC Due Date:
11/10/2023
Plan of Correction
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Administrator to submit an infection control plan to LPA by 11/10/2023.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, water temperature throughout the facility measured between 85.1 degrees F to 95.7 degrees F.
POC Due Date:
11/10/2023
Plan of Correction
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Administrator will have outside contractors come to the facility to adjust water temperature to ensure water temperature in rooms and communal sinks is between 105 degrees F and 120 degrees F. Administrator shall notify LPA when water temperature has been fixed.
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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on obserations, LPA observed furniture on the outdoor passageway which can cause tripping hazards and fire safety hazards.
POC Due Date:
11/10/2023
Plan of Correction
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Administrator will remove furniture on the outdoor passageway and provide LPA with photos
Type B
Section Cited
HSC
1569.625(c)
Other Provisions
(c) The training shall include, but not be limited to, all of the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on record review, administrator was unable to provide LPA with staff training documentation; dementia care, safe food handling, emergency disaster drills, etc.
POC Due Date:
11/10/2023
Plan of Correction
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Administrator to provide LPA copies of staff training for staff files reviewed.
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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, facility did not have the following information readily available; resident roster with resident date of birth, resident's medication list, resident's emergency contact sheet, and resident needs and service plan (for each resident)
POC Due Date:
11/10/2023
Plan of Correction
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Administrator will put together a binder containing all of the information as mentioned above.
Type B
Section Cited
CCR
87632(d)(2)
Hospice Care Waiver
(2) The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, facility failed to notify Licensing within five days of the initiation of hospice care for Resident 1 (R1).
POC Due Date:
11/10/2023
Plan of Correction
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2
3
4
Administrator shall review CCR 87632 and submit acknowledgement of regulation to LPA.
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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, facility does not have a hospice plan of operation/ care plan for residents who are receiving hospice services.
POC Due Date:
11/10/2023
Plan of Correction
1
2
3
4
Administrator to submit a hospice care plan to LPA by 11/10/2023. This plan should include; staffing, training, services being provided.
Type B
Section Cited
CCR
87705(b)
Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, facility did not have a plan of operation for residents with dementia.
POC Due Date:
11/10/2023
Plan of Correction
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2
3
4
Administrator to submit a plan of operation regarding caring for residents with dementia to LPA by 11/10/2023. This plan should include; staffing, training, services being provided.
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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
11/03/2023 01:33 PM
- 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:
VANESSA CARE HOME II
FACILITY NUMBER:
410508446
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
11/03/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review 4/4 residents did not have an updated physician's report done within the last year. 3/4 resident records observed, were residents who have a diagnosis of dementia.
POC Due Date:
11/10/2023
Plan of Correction
1
2
3
4
Administrator will reach out to resident's physicians to request for an updated physician's report. Administrator to submit copies to LPA
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal (c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review; 4/4 resident records observed did not have an indiviudualized needs and service plan.
POC Due Date:
11/10/2023
Plan of Correction
1
2
3
4
Administrator shall complete a needs and service plan for each resident and submit a copy to LPA
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
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Komal Charitra
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE:
11/03/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/03/2023
LIC809
(FAS) - (06/04)
Page:
8
of
8