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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508557
Report Date: 11/08/2024
Date Signed: 11/08/2024 04:04:55 PM

Document Has Been Signed on 11/08/2024 04:04 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:FARM HILL REST HOMEFACILITY NUMBER:
410508557
ADMINISTRATOR/
DIRECTOR:		RYAN, EVELYN B.FACILITY TYPE:
740
ADDRESS:3646 FARM HILL BLVD.TELEPHONE:
(650) 366-6535
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 6CENSUS: 2DATE:
11/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:William Bautista, Caretaker, Elenita "Ruby" Cruz, Caretaker and Corazon Medina, Lead StaffTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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On November 8, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 10:30 AM to conduct the Annual 1-year required inspection. LPA Calandra was greeted by William Bautista, Caregiver and explained the purpose of the visit. Evelyn Ryan, Administrator was unavailable to join the visit. Corazon Medina, Lead Staff and Elenita "Ruby" Cruz, Caretaker joined the visit later.

LPA Calandra toured the physical plant. This is a 2-story building with 6 bedrooms, 3 bathrooms, a living room, dining room, kitchen, front and back yards, and staff room. All bedrooms had the required furniture and sufficient lighting. No accessible bodies of water or hazards were observed in hallways or the front and back yards. The facility was kept at a comfortable temperature. The hot water temperature was within the required 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired.

All sharp objects were locked and in-accessible to persons in care. All soap, detergent, and poisons were observed to be unlocked and accessible to persons in care but were locked in the presence of the LPA.

LPA Calandra reviewed 5 staff files. All were observed to be mostly complete but missing certain documentation related to training and CPR/First Aid Certification.

A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

All Personal and Incidental (P & I) monies kept at the facility matched the records stored at the facility.

During the visit, the following documents were collected:
- Current Liability Insurance

The facility will send the current LIC 500 and Surety Bond to the Regional Office (RO) by 11/22/2024.




SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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 11/08/2024 04:04 PM - It Cannot Be Edited


Created By: John Calandra On 11/08/2024 at 02:32 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: FARM HILL REST HOME
FACILITY NUMBER: 410508557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

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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CCR 87309(a): Storage Space: Based on observation of three cans of Lysol, a bottle of Dove shampoo, and other products that were unlocked and accessible to persons in care, the Licensee did not comply with the section cited above, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2024
Plan of Correction
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During the visit, staff moved bottles of Lysol, Dove shampoo and other products to another cabinet that was locked in the presence of the LPA.

Deficiency cleared during visit.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87355(e)(3) Criminal Record Clearance: Based on record review, S1 is not currently associated to the facility, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/09/2024
Plan of Correction
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Administrator/Licensee to ensure that S1 is associated to the facility and submit a plan to the RO detailing how they plan to ensure all staff will be associated to the facility.
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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 11/08/2024 04:04 PM - It Cannot Be Edited


Created By: John Calandra On 11/08/2024 at 02:32 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: FARM HILL REST HOME
FACILITY NUMBER: 410508557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87305(a): Alterations to Existing Buildings or New Facilities: Based on interview of S3, the facility has a building permit for the staff room downstairs in the garage which on the facility sketch supplied to the Department is labeled as a storage room, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator/Licensee to submit a copy of the building permit to the RO by the POC due date.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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HSC 1569.619(c)(3) Other Provisions: Based on record review only S1 had a valid CPR training certificates in their file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Administrator/Licensee to submit copies of employees CPR training or have staff retake CPR training to the RO by the POC 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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 11/08/2024 04:04 PM - It Cannot Be Edited


Created By: John Calandra On 11/08/2024 at 02:32 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: FARM HILL REST HOME
FACILITY NUMBER: 410508557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87412(a)(11) Personnel Records: Based on record review of S2's file which was missing S2's health screening report and proof of TB results, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Licensee/Administrator to provide S2's health screening report by the POC due date.
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
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HSC 1569.625(b)(2): Other Provisions: Based on record review, training records for S2 for 2024 were not available and staff training records from 2023 showed only 6 hours total of Dementia Care training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee/Administrator to submit a copy of 2024 training records showing the required Dementia Care training has been completed by POC 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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 11/08/2024 04:04 PM - It Cannot Be Edited


Created By: John Calandra On 11/08/2024 at 02:32 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: FARM HILL REST HOME
FACILITY NUMBER: 410508557

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 87411(c)(6) Personnel Requirements-General: Based on record review of staff files all were missing 2024 training records, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee/Administrator to submit all 2024 training records to Licensing by POC due date.
Type B
Section Cited
HSC
1569.319(a)
Regulations
(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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HSC 1569.319(a) Regulations: Based on observation and interview of S2 the facility has two iPads for residents but neither is currently workining, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/15/2024
Plan of Correction
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Licensee/Administrator to obtain at least one internet access device, such as a computer, smart phone, tablet, or other device or will obtain a new charger for current devices by the POC 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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FARM HILL REST HOME
FACILITY NUMBER: 410508557
VISIT DATE: 11/08/2024
NARRATIVE
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********************************************This is an AMENDED Report**************************************************

During the visit, LPA Calandra noticed through record review that S1 has fingerprint clearance but is not currently associated to the facility per review of Guardian (Finger print/Criminal Record Clearance system). Per interview with S1, LPA learned that S1 assists clients/persons in care with activities of daily living such as bathing, dressing, etc. The facility was assessed a Civil Penalty of $500 ($100 a day x 5 days) because S1 has been working at the facility from 10/3/2024 to 11/8/2024 without being associated to the facility.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

The Annual inspection will be completed at a later date.

An exit interview was conducted. This report was reviewed with Corazon Medina, Lead Staff and a copy of the report along with appeal rights left at the facility.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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