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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508554
Report Date: 12/21/2021
Date Signed: 01/04/2022 01:03:29 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/04/2022 01:03 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:RUSTAN ADULT RESIDENTIAL CARE HOMEFACILITY NUMBER:
410508554
ADMINISTRATOR:RUIZ, NECITAFACILITY TYPE:
735
ADDRESS:147 PLYMOUTH CIRCLETELEPHONE:
(650) 878-8297
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
12/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Giovanni Prado III & Leah RuizTIME COMPLETED:
06:30 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. This one level home consists of 3 client bedrooms and 2 staff rooms--one with a private bathroom. There is one bathroom for all residents, kitchen, dining and living rooms. Facility accommodates Level 2 Regional Center clients. No accessible bodies of water or fire safety hazards are observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate and infection control signs are posted prominently. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 ambulatory residents present, and 1 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed; first-aid training for staff is checked. Leah Ruiz is a certified ARF administrator (x 10/2023) that oversees facility operations.

The following licensing forms/information are requested to be submitted to CCLD by 1/4/21:

- LIC 400 Affidavit Regarding Client Cash Resources
- LIC 402 Surety Bond (or proof of valid surety bonding)
- LIC 308 Designation of Administrative Responsibility
- LIC 500 Personnel Report
- LIC 610 Emergency Disaster Plan
- LIC 999 Facility Floor Plan (with dimensions)
- LIC 808 COVID-19 Mitigation Plan

Annual fee is overdue and amount of $454 is due and payable.

Deficiency of the CA Code of Regulations, Title 22, Division 6, is cited on a following page. See also Technical Advisory note.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2021
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 01/04/2022 01:03 PM - It Cannot Be Edited


Created By: Audrey Jeung On 12/22/2021 at 10:52 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: 12/21/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2021
Section Cited
CCR
80019(e)

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Dept.
This requirement is not met as evidenced by absence of criminal record clearance for 2 staff.
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Staff 1 and staff 2 will not be permitted to be on premises with clients unless and until they have obtained criminal record clearances. Additional civil penalties may be assessed for failure to comply.
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Based on interview with staff and absence of criminal record clearance documentation for staff 1 and staff 2, the licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care. Civil penalty of $200 is assessed.
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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:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2021


LIC809 (FAS) - (06/04)
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