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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508554
Report Date: 09/27/2024
Date Signed: 09/27/2024 12:06:54 PM

Document Has Been Signed on 09/27/2024 12:06 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:RUSTAN ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508554
ADMINISTRATOR/
DIRECTOR:		LEAH RUIZFACILITY TYPE:
735
ADDRESS:147 PLYMOUTH CIRCLETELEPHONE:
(650) 878-8297
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 5DATE:
09/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Caregiver, Rowenda PradoTIME VISIT/
INSPECTION COMPLETED:
12:20 PM
NARRATIVE
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On September 27, 2024, Licensing Program Analysts (LPAs) Komal Charitra and Kiran Jain conducted an unannounced annual inspection. LPAs met with Caregiver, Rowenda Prado and Administrator, Leah Ruiz and explained the purpose of the visit.

LPA toured the facility inside and outside including all of client rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. LPA observed three shared client rooms and two staff rooms. All client rooms were observed with required furniture. Client room #2 was observed to have a closet door in disrepair and client room #3 was observed to have a broken dresser. LPAs observed a exit passageway from client room #3 to the backyard. Sliding door in room #3 was observed to have no handle to open the door and no lock on the door. Two staff rooms were observed for live-in staff with their personal belonging. Two full bathrooms were observed; one client bathroom was observed in the hallway equipped with liquid soap and paper-towels and another full bathroom in staff room 1.

Extra linen was present. First aid kit was observed present and complete. Water temperature throughout the facility measured at 127 degrees F. Living room and dining room were observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be unlocked an accessible to clients. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of May 2024. LPAs observed garage to have washer and dryer in good repair. Chemicals cabinet in garage was observed locked, however key was attached to the lock. Fire drills are being conducted and logged quarterly.

LPAs reviewed 5 client records and 4 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.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator. A copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2024
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 3
Document Has Been Signed on 09/27/2024 12:06 PM - It Cannot Be Edited


Created By: Komal Charitra On 09/27/2024 at 11:31 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: RUSTAN ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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, LPAs observed unlocked and accessible chemicals in the bathroom and under the kitchen sink, sharps in kitchen were observed to be unlocked, and the chemical cabinet in the garage had a lock, however the key was attached to the lock which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2024
Plan of Correction
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Administrator/Licensee shall provide in-service training to caregivers in relation to the importance of locking chemicals and sharps.
Type A
Section Cited
CCR
80075(k)(1)
(k) The following requirements shall apply to medications which are centrally stored: (1) Medication shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, medications were observed to be unlocked and accessible to clients in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2024
Plan of Correction
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Administrator/Licensee shall lock the medications that are in the safe located in the kitchen and provide LPA photos for proof. Training shall be provided to all staff member to ensure medication will be locked and inaccessible to all clients in care.
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:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/27/2024 12:06 PM - It Cannot Be Edited


Created By: Komal Charitra On 09/27/2024 at 11:31 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: RUSTAN ADULT RESIDENTIAL CARE HOME
FACILITY NUMBER: 410508554

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/27/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPAs observed broken closet door in client bedroom #2, broken dresser drawer in client bedroom #3, the sliding door located in client bedroom #3, was observed to not have a lock or a door handle which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee/Administrator shall repair all of the above mentioned items that are in disrepair and send LPA photos of repaired items by 10/4/2024.
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, water temperature throughout the facility measured at 127 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee/Administrator shall adjust water heater/water temperature and provide LPA proof by photo or video that water temperature is between 105-120 degrees F.
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:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3