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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508866
Report Date: 11/18/2021
Date Signed: 11/19/2021 08:52:50 AM

Document Has Been Signed on 11/19/2021 08:52 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
CCLD Regional Office,
, CA
FACILITY NAME:CARE PLUS HOMEFACILITY NUMBER:
410508866
ADMINISTRATOR:ESTRELLA MANIOFACILITY TYPE:
735
ADDRESS:34 CAPAY CIRCLETELEPHONE:
(650) 225-9128
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 6DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Edwin Bactad, House ManagerTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tobola arrived unannounced to conduct a Required - 1 Year inspection and met with House Manager, Edwin Bactad (EB). LPA contacted Licensee James Hsiao and notified of the inspection. The annual inspection is focused on the Infection Control procedures and practices of this Adult Residential Facility. There are 6 clients in care, 1 of which was with family at the time of visit.

LPA toured facility and grounds with House Manager and observed COVID-19 precaution signs posted in common areas to promote hand washing and physical distancing. LPA was screened for COVID-19 symptoms upon entrance to this facility. Visitors are said to be screened for COVID-19 symptoms (including temperature check) upon arrival to the facility. Facility has not submitted a mitigation plan to CCL for review. LPA informed that staff do not monitor clients for symptoms on a daily basis. LPA explained the importance of monitoring for COVID to House Manager. LPA observed at least a 30-day PPE supply for client use. Cleaning and disinfecting the facility common areas is conducted three times per week and staff stated high touched surface areas are disinfected after each use, such as the bathroom and kitchen area. Common areas are equipped with hand sanitizer and masks available for client use. Bathrooms are equipped with liquid soap and paper towels available upon client request. Caregivers have completed PPE training as well as N-95 Mask Fit Testing Training for all staff.

In addition, facility was found to be at a comfortable temperature with all exits free from obstruction. No accessible bodies of water were observed. Fire Extinguisher was missing service tag with no receipt to indicate the last inspection or purchase date. Smoke and Carbon monoxide detectors were tested and fully operational.
There was sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit.
Continued onto LIC809-C
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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
CCLD Regional Office,
, CA
FACILITY NAME: CARE PLUS HOME
FACILITY NUMBER: 410508866
VISIT DATE: 11/18/2021
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LPA observed scissors unsecured in client bedroom as well as a knife located in the backyard which were both immediately removed. Client medications are stored in a secured staff storage area however LPA found that client (C1) was found to be holding several prescription medications in their bedroom. LPA and staff attempted to retrieve medication but C1 refused demonstrating aggressive verbal behavior.

LPA observed a collection of trash and food in client C2's bedroom which is to be kept clean on a daily basis. In addition, LPA found multiple ants covering a plate of pastries located in C2's bedroom. House Manager agrees to develop plan to keep C2's bedroom maintained. LPA also observed mildew along client bathroom ceiling causing paint to peel. Window latch in client bathroom was also found to be in disrepair.

- Administrator to submit COVID Mitigation Plan to CCL by 11/22/2021

LPA requested the following updated documents to be submitted to CCLD by 11/22/2021:
  • LIC500 Personnel Report
  • LIC308 Designation of Administrative Responsibility
  • LIC610 Emergency Disaster Plan
  • Administrator Certification

Exit interview conducted with House Manager, whose signature on this document confirms receipt.
Due to printer malfunction, this report was emailed to House Manager and Licensee.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/19/2021 08:52 AM - It Cannot Be Edited


Created By: Dominic Tobola On 11/18/2021 at 03:35 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
,
, CA

FACILITY NAME: CARE PLUS HOME
FACILITY NUMBER: 410508866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that 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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Based on LPA observation, the licensee did not comply with the section cited above in 2 out of 2 sharp objects (knife and scissors) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2021
Plan of Correction
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Licensee failed to ensure sharp objects that pose a danger to clients if readily available were secured. Items were immediately removed and secured at the time of visit. Deficiency cleared.
Type A
Section Cited
CCR
80087(h)
Building and Grounds
(h) Medicines shall be stored as specified in Section 80075(m) and (n) and separately from other items specified in Section 80087(g) above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation and interview with client (C1), the licensee did not comply with the section cited above in properly storing medication for clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee failed to ensure medicines are stored in a secured location and inaccessible to other clients. Licnesee is to develop a plan to remove all medications from C1's bedroom and to reassess client C1's capability with the facility. Plan is to be submitted to CCL by 11/22/2021.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/19/2021 08:52 AM - It Cannot Be Edited


Created By: Dominic Tobola On 11/18/2021 at 03:35 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
,
, CA

FACILITY NAME: CARE PLUS HOME
FACILITY NUMBER: 410508866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80020(a)
Fire Clearance
(a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 fire extinguishers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2021
Plan of Correction
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Licensee failed to ensure fire extinguisher was equipped with service tag or proof of inspection. Licensee agrees to contact the local fire department for an immediate inspection. Licensee is to submit LIC9098 Proof of Corrections to CCL by POC due date 11/22/2021. In addition, Licensee is to submit a photo of inspected fire extinguisher to CCL by POC due date. 11/25/2021.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/19/2021 08:52 AM - It Cannot Be Edited


Created By: Dominic Tobola On 11/18/2021 at 03:35 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
,
, CA

FACILITY NAME: CARE PLUS HOME
FACILITY NUMBER: 410508866

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation the licensee did not comply with the section cited above in 2 out of 2 items (bathroom ceiling & window latch in disrepair, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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Licensee failed to ensure facility is in good repair at all times. Licensee is to submit photo proof of repairs to the indicated items to CCL by POC due date, 12/2/2021.
Type B
Section Cited
CCR
80087(a)(1)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 client bedroom in unsanitary conditions causing insects in client living space, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/02/2021
Plan of Correction
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Licensee failed to ensure facility was kept sanitary and free from insects. Licensee agrees to develop a plan to manage client C2's sanitation behaviors and ensure facility is free of insects. Licensee is to submit photo proof of C2's bedroom in sanitary condition to CCL by POC due date 12/02/2021 as well as a plan to ensure facility is in compliance moving forward.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Dominic Tobola
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
Page: 5 of 5