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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508608
Report Date: 09/28/2022
Date Signed: 09/28/2022 11:03:19 AM

Document Has Been Signed on 09/28/2022 11:03 AM - 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:CARING HEARTS HOME #1FACILITY NUMBER:
410508608
ADMINISTRATOR:YATCO, FLORINDAFACILITY TYPE:
735
ADDRESS:927 CRANE AVENUETELEPHONE:
(650) 571-8994
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 6CENSUS: 6DATE:
09/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Caregiver, Angelina Cruz TIME COMPLETED:
11:10 AM
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On September 28, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 8/6/22. LPA met with Caregiver, Angelina Cruz and explained the purpose of visit

On August 8, 2022, the Licensee reported that Resident #1 (R1) AWOL (Absent Without Official Leave) on 8/6/2022. During the visit, LPA reviewed R1’s file and interviewed staff. According to the file reviewed, R1 has a diagnosis of Moderate Intellectual Disability and Schizophrenia. In addition, documents reviewed indicates that although R1 is able to leave the facility unassisted, R1 requires a 1 on 1 staff as a result of R1’s history of AWOL. R1 was missing for about an hour and was returned to the community by local police department.

Based on the file reviewed and interviews conducted, the facility did not ensure basic services were being met. Due to lack of supervision, R1 AWOL.

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

Report is reviewed with Caregiver, Angeline Cruz and a copy is provided with appeals rights.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2022
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 09/28/2022 11:03 AM - It Cannot Be Edited


Created By: Komal Charitra On 09/28/2022 at 10:43 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: CARING HEARTS HOME #1
FACILITY NUMBER: 410508608

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2022
Section Cited
CCR
80065(a)

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80065 Personnel Requirements: (a) Facility personnel shall be competent to provide the services necessary to meet individual client needs and shall, at all times, be employed in numbers necessary to meet such needs.

Violation of this regulation is evidence by:
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Facility administrator will submit a plan to LPA regarding how facility will ensure R1's needs are met. For ex: if assigned caregiver takes a break, how will facility ensure R1's needs and services are met. In addition, LPA observed the door alarms that were installed at all exit doors.
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Based on the file reviewed and interviews conducted, the facility did not ensure basic services were being met. In addition, it was indicated that R1 has a history of AWOL. Due to lack of supervision, R1 AWOL.
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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:Jackie Jin
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2022


LIC809 (FAS) - (06/04)
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