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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
410508866
Report Date:
08/01/2024
Date Signed:
08/01/2024 05:37:57 PM
Document Has Been Signed on
08/01/2024 05:37 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
ADMINISTRATOR/
DIRECTOR:
ESTRELLA MANIO
FACILITY TYPE:
735
ADDRESS:
34 CAPAY CIRCLE
TELEPHONE:
(650) 225-9128
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
6
CENSUS:
6
DATE:
08/01/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:17 PM
MET WITH:
Nenita Bactad & Edwin Bactad
TIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 8/1/2024, LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with care staff Nenita Bactad & Edwin Bactad. LPA explained the purpose of the visit.
LPA toured the facility inside and outside. While touring the facility it was observed that the temperature was af 70 deg F. Hot water was also tested and temperature was within required range. The residents have adequate amount of incontinence care items. All personal belongings are intact. All fire extinguishers have been checked. Medication review was done and all medications are accounted for and centrally stored medication records are updated.
Each resident rooms were checked. R1 & R3s sheets and mattresses are not intact and have holes or is torn. 4 carbon monoxide monitors are not working. There is no adequate amount of food for 2 days perishables and & 7 days non-perishable. Bathroom was observed to be in disrepair, handles in the shower area have caulking and shower floor needs to be updated.
Four staff records were reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, it was noted that the facility does not have updated CPR & First Aid training. Administrator certificates are not updated. Six resident records are checked and a lot of records are missing and needs to be updated. Facility doesn't have an updated record of Emergency Disaster drill log.
Care staff tried to contact the Administrator/Licensee but there was no reply.
page 1 of 2
SUPERVISORS NAME
:
Andrea Medlin
LICENSING EVALUATOR NAME
:
Grace Donato
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
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
8
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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
VISIT DATE:
08/01/2024
NARRATIVE
1
2
3
4
5
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11
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22
23
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25
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27
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LPA requested licensee to submit the following by 8/9/2024::
LIC 308 Designation of Facility Responsibility
LIC 500 Personnel Report
Updated Administrator Certificate or application submitted for renewal.
Updated First Aid Trainings
Emergency Disaster Plan
Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.
Report is reviewed and a copy is provided with appeal rights.
page 2 of 2
SUPERVISORS NAME
:
Andrea Medlin
LICENSING EVALUATOR NAME
:
Grace Donato
LICENSING EVALUATOR SIGNATURE
:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
2
of
8
Document Has Been Signed on
08/01/2024 05:37 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/01/2024
at
03:46 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/01/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the licensee did not comply with the section cited above due to 4 carbon monoxide detectors not working in residents rooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/08/2024
Plan of Correction
1
2
3
4
Licensee to update/change the carbon monoxide detectors. Licensee to submit proof of change such as photo or video
Type A
Section Cited
CCR
80088(e)(3)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (3) All toilets, handwashing and bathing facilities shall be maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences shall be provided in facilities accommodating physically handicapped clients who need such items.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation the bathroom is in disrepair due to handles in the shower area have caulking and shower floor needs to be updated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/08/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to address the repairs needed for the shower area. Licensee to submit proof of change to LPA.
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:
Andrea Medlin
LICENSING EVALUATOR NAME:
Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
3
of
8
Document Has Been Signed on
08/01/2024 05:37 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/01/2024
at
03:46 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/01/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85088(c)(4)
Fixtures, Furniture, Equipment, and Supplies
(c) The licensee shall ensure provision to each client of the following furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. (4) Clean linen in good repair, including lightweight, warm blankets and bedspreads; top and bottom bed sheets; pillow cases; mattress pads; rubber or plastic sheeting, when necessary; and bath towels, hand towels and wash cloths.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation each resident rooms were checked. R1 & R3s sheets and mattresses are not intact and have holes or is torn, bed frame for R3 needs to be fixed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan on how the facility will upgrade/update the furnitures that the residents use. Licensee to submit proof after change has been done to LPA.
Type A
Section Cited
CCR
85064(b)
Administrator Qualifications and Duties
(b) All adult residential facilities shall have a qualified and currently certified administrator.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based record review, Administrator certificates are not updated which poses an immediate health, safety or personal rights risk to persons in care
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to update the certificates. Licensee to submit proof once renewal has been submitted.
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:
Andrea Medlin
LICENSING EVALUATOR NAME:
Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
4
of
8
Document Has Been Signed on
08/01/2024 05:37 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/01/2024
at
03:46 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/01/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(f)
Health-Related Services
(f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review 4 out of 4 staff records dont have an updated first aid training certificate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to keep training up to date. Licensee to submit proof to LPA once training is done.
Type A
Section Cited
CCR
85076(d)(1)
Food Service
(1) Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, there is not enough 2 day perishable and 7 day non-perishable food supply for residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to address food supply in the facility. Licensee to submit proof that there is enough food supply for residents.
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:
Andrea Medlin
LICENSING EVALUATOR NAME:
Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
5
of
8
Document Has Been Signed on
08/01/2024 05:37 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/01/2024
at
03:46 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/01/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.2(b)(1)(C)
Needs and Services Plan
(b) If the client is to be admitted, then prior to admission, the licensee shall complete a written Needs and Services Plan, which shall include: (1) The client's desires and background, obtained from the client, the client's family or his/her authorized representative, if any, and licensed professional, where appropriate, regarding the following: (C) The written medical assessment specified in Section 80069.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, 2 out of 6 residents don't have a written needs and services plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to update the records of the residents. Licensee to submit by POC deadline.
Type A
Section Cited
CCR
85068.2(b)(1)(G)1
Needs and Services Plan
1. The licensee shall document the initial assessment based on information available at the time of the assessment. This information shall be maintained and brought current thereafter as needed.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review 2 out of six have no initial assessments on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to update the records of the residents. Licensee to submit by POC deadline.
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:
Andrea Medlin
LICENSING EVALUATOR NAME:
Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
6
of
8
Document Has Been Signed on
08/01/2024 05:37 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/01/2024
at
03:46 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/01/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based records review 3 out of 6 residents don't have medical assessments or physicians report which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to update the records of the residents. Licensee to submit by POC deadline.
Type A
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based records review, Licensee did not have an updated emergency drill log which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to ensure that emergency drills are done at least every quarter. Licensee to submit initial in-service training as proof to Licensing. Licensee to submit by POC deadline.
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:
Andrea Medlin
LICENSING EVALUATOR NAME:
Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
7
of
8
Document Has Been Signed on
08/01/2024 05:37 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/01/2024
at
03:46 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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
08/01/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80070(a)
Client Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained in the facility for each client.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review 6 out of 6 residents don't have updated records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/02/2024
Plan of Correction
1
2
3
4
Licensee to submit a plan to update the records of the residents. Licensee to submit by POC deadline.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
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:
Andrea Medlin
LICENSING EVALUATOR NAME:
Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE:
08/01/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/01/2024
LIC809
(FAS) - (06/04)
Page:
8
of
8