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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508864
Report Date: 07/24/2024
Date Signed: 07/24/2024 05:49:48 PM

Document Has Been Signed on 07/24/2024 05:49 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:FHAR - MERCED DRIVE HOMEFACILITY NUMBER:
410508864
ADMINISTRATOR/
DIRECTOR:		SURDEL, PHILFACILITY TYPE:
735
ADDRESS:270 MERCED DRIVETELEPHONE:
(650) 403-0403
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
07/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator, Phil SurdelTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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On July 24, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator, Phil Surdel and house manager, Shanda Villanueva and explained the purpose of the visit.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction.

This is a two story facility. The main entrance is on the top floor which includes two shared resident bedrooms with a full bathroom, office, kitchen, and common area. The lower level has a living room, the laundry room, one shared resident bedroom and one full bathroom inside of the laundry room.

LPA observed furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort

Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FHAR - MERCED DRIVE HOME
FACILITY NUMBER: 410508864
VISIT DATE: 07/24/2024
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Hot water temperature in the kitchen and bathroom were measured at 105-116 degrees Fahrenheit. Fire extinguishers were checked.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (1) staff files was conducted and noted on the LIC 859.

A review of 5 P & I was conducted and based on the Client/ Resident Personal Property and Valuables form, LPA observed 5 out of 5 residents did not have a mark or a signature from the resident or the authorized representative when cash was dispensed and there were several missing store receipts.

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 of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/24/2024 05:49 PM - It Cannot Be Edited


Created By: Murial Han On 07/24/2024 at 02:11 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 - MERCED DRIVE HOME
FACILITY NUMBER: 410508864

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2024

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


This requirement is not met as evidenced by: 80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 5 out of 5 residents did not have a mark or a signature when cash was dispensed and there were several missing store receipts which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/31/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 7/31/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 07/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/24/2024


LIC809 (FAS) - (06/04)
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