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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
410508482
Report Date:
02/13/2024
Date Signed:
02/13/2024 03:24:38 PM
Document Has Been Signed on
02/13/2024 03:24 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:
PETANI HAVEN
FACILITY NUMBER:
410508482
ADMINISTRATOR:
HAUPEAKUI, ANE
FACILITY TYPE:
740
ADDRESS:
1840 EVERGREEN STREET
TELEPHONE:
(650) 343-8153
CITY:
SAN MATEO
STATE:
CA
ZIP CODE:
94401
CAPACITY:
6
CENSUS:
2
DATE:
02/13/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
09:30 AM
MET WITH:
Ane Haupeakui
TIME COMPLETED:
03:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including detached storage building. There are 3 shared client bedrooms, a staff room, 2 full bathrooms, living/dining room, TV room, and kitchen. Washer and dryer are located in 1-car garage. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is maintained and complete. Client files are reviewed, including Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records.
Ane Haupeakui and Tomasi Haupeakui oversee facility operations; Tomasi's RCFE administrator certificate expires 2/25.
As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895.
Proof of current liability insurance is given to LPA today.
The following licensing forms are requested to be completed and submitted to CCLD BY 2/27/24:
- Designation of Administrative Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (revised 9 page LIC610-E signed and dated on page 9)
- Facility Sketch (LIC999)
Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Advisory Notes--5 pages.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
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
6
Document Has Been Signed on
02/13/2024 03:24 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:
PETANI HAVEN
FACILITY NUMBER:
410508482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, as Client #2 is bedridden, as per MD report 1/24 and facility does not maintain bedridden fire clearance.
This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/14/2024
Plan of Correction
1
2
3
4
Plan of correction to be submitted to CCLD BY DUE DATE
Type A
Section Cited
CCR
87412(b)(3)
Personnel Records
(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and staff record review, the licensee did not comply with the section cited above, as Staff #6 is observed having contact with client #2, and does not have criminal record clearance and association with facility.
This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/14/2024
Plan of Correction
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2
3
4
Staff #6 must maintain criminal record clearance and association with facility and proof of correction shall be submitted to CCLD BY DUE DATE. All volunteers must have criminal record clearance and association with facility in order to have contact with clients.
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:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
02/13/2024 03:24 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:
PETANI HAVEN
FACILITY NUMBER:
410508482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, 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 physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above, as 4 out of 5 staff do not have evidence of health screening and TB test results on file, which poses a potential health, safety or personal rights risk to persons in care. Staff #2, #3, #4, #5 do not have HS and TB results on file.
POC Due Date:
02/27/2024
Plan of Correction
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2
3
4
Copies of health screenings and TB test results for Staff #2, #3, #4, #5 will be sent to CCLD BY DUE DATE.
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:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
02/13/2024 03:24 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:
PETANI HAVEN
FACILITY NUMBER:
410508482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above, as there is no documentation maintained that staff have received required 4 hours of training on postural supports, hospice care and restricted health conditions.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/27/2024
Plan of Correction
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2
3
4
Proof that staff have received required 4 hours of training on postural supports, hospice care and restricted health conditions will be sent to CCLD BY DUE DATE.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that staff #1, #2, #3, #5 have current first aid training.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/27/2024
Plan of Correction
1
2
3
4
Proof of current first aid training for staff to be sent to CCLD BY DUE DATE.
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:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
02/13/2024 03:24 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:
PETANI HAVEN
FACILITY NUMBER:
410508482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(2)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (2) Eight hours of in-service training per year on the subject of serving residents with dementia. This training shall be developed in consultation with individuals or organizations with specific expertise in dementia care or by an outside source with expertise in dementia care. In formulating and providing this training, reference may be made to written materials and literature on dementia and the care and treatment of persons with dementia. This training requirement may be satisfied in one day or over a period of time. This training requirement may be provided at the facility or offsite and may include a combination of observation and practical application.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that staff have required dementia training.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/27/2024
Plan of Correction
1
2
3
4
Proof that staff have received required 8 hours of dementia training will be sent to CCLD BY DUE DATE.
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:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
Document Has Been Signed on
02/13/2024 03:24 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:
PETANI HAVEN
FACILITY NUMBER:
410508482
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
02/13/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 client record review, the licensee did not comply with the section cited above, as pre appraisals and/or reappraisals for both clients are not maintained. Client #1 was admitted 7/2020 and client #2 admitted 7/2023.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/27/2024
Plan of Correction
1
2
3
4
Copies of signed and dated appraisals for clients #1 and #2 will be sent to CCLD BY DUE DATE.
Type B
Section Cited
CCR
87705(c)(5)
CARE OF PERSONS WITH DEMENTIA
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 client record review, the licensee did not comply with the section cited above, as client #1--who is diagnosed with dementia--has MD report dated more than 1 year ago, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/27/2024
Plan of Correction
1
2
3
4
Updated MD report for client #1 will be sent to CCLD BY DUE DATE
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:
Audrey Jeung
TELEPHONE:
(650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE:
02/13/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
02/13/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6