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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508446
Report Date: 01/21/2025
Date Signed: 01/21/2025 01:14:18 PM

Document Has Been Signed on 01/21/2025 01:14 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VANESSA CARE HOME IIFACILITY NUMBER:
410508446
ADMINISTRATOR/
DIRECTOR:		GALATI, IDAFACILITY TYPE:
740
ADDRESS:1640 ELEANOR DRIVETELEPHONE:
(650) 315-2114
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY: 6CENSUS: 5DATE:
01/21/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Tina GalatiTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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LPA Jeung met with staff to discuss and review deficiencies cited on 9/20/24 during annual inspection--for which proof of corrections was not received--and to issue citation for first-aid certificates of 4 staff that were verified to be falsified by National CPR Foundation. On 10/4/24, licensee submitted first-aid certificates from National CPR Foundation for the same 4 staff, showing that the date completed was 9/30/24.

Deficiencies are cited on a following page as per California Code of Regulations, Title 22, which includes deficiencies observed on 9/20/24.

Ms. Galati is advised that annual fee of $742 is due and payable. Licensee is advised to obtain proof of payment from bank.

The following licensing forms are requested to be submitted to CCLD BY 2/4/25:

- LIC 308 Designation of Facility Responsibility
- LIC 500 Personnel Report
- LIC 999 Facility Sketch (including dimensions)

Acknowledgement of corrections made as per 9/20/24 citations issued is given to Ms. Galati--4 pages,
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 01/21/2025 01:14 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/21/2025 at 10:47 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: VANESSA CARE HOME II
FACILITY NUMBER: 410508446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/22/2025
Section Cited
CCR
87207

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FALSE CLAIMS
No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement was not met, as certificates of first-aid training for 4 staff
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Plan of correction will be submitted to CCLD BY DUE DATE, describing how false or misleading statements will NEVER be made or disseminated by any staff, including licensee.
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were falsified. Licensee disseminated false information regarding first-aid training for staff, which poses an immediate health, safety, or personal rights risk to clients in care. National CPR Foundation certificates of completion for staff #2, #3, #4, #6 observed 9/20/24 are dated 5/11/25.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/21/2025 01:14 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/21/2025 at 12:42 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: VANESSA CARE HOME II
FACILITY NUMBER: 410508446

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2025
Section Cited
CCR
87411(f)

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PERSONNEL REQUIREMENTS
All personnel... shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a
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Health screening and TB test result for staff #2 to be sent to CCLD BY DUE DATE
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physician not more than 6 months prior to or 7 days after employment or licensure.
This requirement was not met, as there is no health screening and TB test result for staff #2. Licensee failed to ensure that all staff have health screeningTB test result, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
02/04/2025
Section Cited
HSC1569.625(b)(2)

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HEALTH AND SAFETY CODE
... training requirements shall...include an additional 20 hours annually, 8 hours of which shall be dementia care training...& 4 hours of which shall be specific to postural supports, restricted health conditions, & hospice care, as required by subdivision (a) of Section 1569.696.
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Proof of annual 8 hours of dementia training, 4 hours of annual hospice, restricted health conditions and postural supports training for all staff will be sent to CCLD BY DUE DATE
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This requirement was not met, as it cannot be determined if staff have received at least 8 hours of dementia training and 4 hours of annual hospice, restricted health conditions, and postural supoorts training, which poses a potential health, safety or personal rights risk to clients in care.
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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:April Cowan
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/21/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/21/2025


LIC809 (FAS) - (06/04)
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