410508747-7-14-2020-26-AS-DMAO-BRHVEK-20200714162228

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 410508747
Report Date: 07/14/2020
Date Signed: 07/14/2020 04:23:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	PENISONI CARE HOME		FACILITY NUMBER:	410508747
ADMINISTRATOR:	PENISONI, KOLOTINA L.		FACILITY TYPE:	740
ADDRESS:	2736 GEORGETOWN STREET		TELEPHONE:	(650) 323-5844
CITY:	EAST PALO ALTO	STATE: CA	ZIP CODE:	94303
CAPACITY:	9	CENSUS: 7	DATE:	07/14/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Sione Penisoni		TIME COMPLETED:	03:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) David Marrufo conducted an unannounced Case Management tele-visit and spoke with Sione Penisoni. The visit was conducted over telephone due to the ongoing COVID-19 Shelter-in-Place order throughout the county and state. On 06/10/2020, the Department received a complaint alleging that facility staff threatened a resident with eviction. During the investigation, LPA Marrufo became aware that an eviction notice had been issued to R1 on 06/13/2020, rather than to the responsible party; therefore, the eviction notice does not meet the requirements under Section 87224 Eviction Procedures. During the investigation, LPA Marrufo also obtained the latest copy of R1’s Admission Agreement dated 1/18/2020 which lacks the resident conservator’s signature; therefore, it is considered invalid since it has not been properly discussed and signed by the responsible party. Furthermore, the agreement raises the basic monthly rate, and fails to provide the required 60 days-notice of such increase. The resident’s responsible party verified that he/she did not receive a new agreement with the rate increase and did not receive a written notice of eviction from the facility. See LIC809-C page for more information. Page 1 of 2.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

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 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PENISONI CARE HOME	FACILITY NUMBER: 410508747
	VISIT DATE: 07/14/2020

NARRATIVE

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Based on records review, interviews and observations there is preponderance of evidence to prove the following: the facility issued an illegal Admissions Agreement for R1 since it was not signed by R1’s conservator, the facility illegally increased the monthly rate for R1 since the facility did not issue a written notice of rate increase to R1’s conservator, and the facility illegally evicted R1 since the facility did not issue a written notice of eviction to R1’s conservator.

See 809-D for deficiencies cited per the California Code of Regulations, Title 22.

This report was reviewed with Sione Penisoni. A copy of this report will be sent to him to sign and return to LPA Marrufo. Sione Penisoni was also provided with a copy of Appeal Rights.

SUPERVISOR'S NAME: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC809 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PENISONI CARE HOME	FACILITY NUMBER: 410508747
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/21/2020 Section Cited	1 2 3 4 5 6 7	Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the
	8 9 10 11 12 13 14	licensee’s designated representative no later than seven days following admission. This requirement was not met as evidenced by: Licensee did not have R1’s admission agreement signed by R1’s representative, which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	submit a statement of understanding to CCL by POC date.
Type B 07/21/2020 Section Cited	1 2 3 4 5 6 7	The licensee shall, in addition to either serving the required thirty (30) days-notice, sixty (60) days-notice or seeking approval from the Department and service three (3) days-notice on the
	8 9 10 11 12 13 14	resident, notify or mail a copy of the notice to quit to the resident's responsible person. This requirement was not met as evidenced by: Licensee did not notify R1’s responsible party of eviction, which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14	eviction notice to R1’s responsible person and submit a copy to CCL by POC 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: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC809 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: PENISONI CARE HOME	FACILITY NUMBER: 410508747
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/21/2020 Section Cited	1 2 3 4 5 6 7	If a licensee of a residential care facility for the elderly increases the rates of fees for residents or makes increases in any of its rate structures for services, the licensee shall provide no less
	8 9 10 11 12 13 14	than 60 days' prior written notice to the residents or the residents' representatives setting forth the amount of the increase, the reason for the increase, and a general description of the additional costs, except for an increase in the rate due to a change in the level of care of the resident. This requirement was not met as evidenced by: Licensee failed to provide written notice of rate change to R1’s representative, which poses a potential safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: George Nwafor	TELEPHONE: (408) 324-2116
LICENSING EVALUATOR NAME: David Marrufo	TELEPHONE: (650) 380-0519
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2020

LIC809 (FAS) - (06/04)

Page: 4 of 4