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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508815
Report Date: 02/07/2024
Date Signed: 02/07/2024 04:50:19 PM

Document Has Been Signed on 02/07/2024 04:50 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:FHAR - SNEATH LANE HOMEFACILITY NUMBER:
410508815
ADMINISTRATOR:SURDEL, PHILFACILITY TYPE:
735
ADDRESS:3600 SNEATH LANETELEPHONE:
(650) 589-6152
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
02/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Phil SurdelTIME COMPLETED:
01:25 PM
NARRATIVE
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On 2/7/2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced annual inspection. LPA met with Administrator, Phil Surdel and manager, Shanda Villanueva and LPA explained the purpose of today's visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. The facility tour consists of: living room, dining room, kitchen and bedrooms. During the visit, there was one client on premises with caregiver and five other client's at day program.

LPA observed client's bedrooms to have adequate lighting and furniture. There are three client's shared bedrooms (2 upstairs and 1 downstairs) and three bathrooms. Hot water was at 106 degrees Fahrenheit. Two days perishable and one week nonperishable food supply observed to be adequate for six clients. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed medications were stored and locked and inaccessible to clients in care. Kitchen tools and knives stored in locked hallway cabinet. Fire extinguishers were mounted and charged. Fire alarm, smoke detectors and carbon monoxide detectors are operational. Fire drills conducted quarterly.

LPA reviewed 4 resident records and all of them contained Admission Agreement, Medical Assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan, Resident Identification information, Pre-Placement Appraisals, GGRC/IPP, etc.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FHAR - SNEATH LANE HOME
FACILITY NUMBER: 410508815
VISIT DATE: 02/07/2024
NARRATIVE
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LPA reviewed 3 staff files and all of them contained Personnel Records, Training Records, Health Screening Records, Job Description, Abuse Statement, First Aid/CPR, Criminal Record Statement, Criminal Background Clearance, etc.

LPA observed staff #1(S1) who was present at the facility during the visit was not associated to the facility until today(2/7/2024) and according to the administrator S1 was hired in May 2023.

LPAs reviewed P& I/ Case Resource Records for 3 clients and 1 out of 3 resident's cash did not reconciled according to the Cash Resource Records.

LPA requested for the following documents to be submitted to CCL by 2/9/2024: administrator certification, control of property, LIC 309, LIC 308, and Emergency Disaster Plan (LIC 610D).

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator.

A copy is provided with the Appeal Rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 02/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 02/07/2024 04:50 PM - It Cannot Be Edited


Created By: Murial Han On 02/07/2024 at 12:36 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: FHAR - SNEATH LANE HOME
FACILITY NUMBER: 410508815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80065(i)(2)


This requirement is not met as evidenced by: LPA observed Staff #1 was not associated with the facility
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as staff # (S1) was hired in May 2023 and based on facility's Guardian Background Record, S1 was associated with the facility today (2/7/2024) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2024
Plan of Correction
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The administrator will submit a plan to CCL by 2/8/2024 ensuring all staff members are associated with the facility prior to employment.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/07/2024 04:50 PM - It Cannot Be Edited


Created By: Murial Han On 02/07/2024 at 12:47 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: FHAR - SNEATH LANE HOME
FACILITY NUMBER: 410508815

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80026(b)


This requirement is not met as evidenced by: Resident #1's available cash did not match the Safeguarded Cash Resources Record.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/14/2024
Plan of Correction
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The administrator will submit a plan to ensure resident's cash amount matches the safeguarded cash resources records transactions. The administrator will provide a copy of the plan and staff in-service record to CCL by 2/14/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2024


LIC809 (FAS) - (06/04)
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