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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
410508866
Report Date:
08/20/2025
Date Signed:
11/10/2025 03:28:24 PM
Document Has Been Signed on
11/10/2025 03:28 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:
08/20/2025
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
01:26 PM
MET WITH:
Nenita Bactad & Edwin Bactad
TIME VISIT/
INSPECTION COMPLETED:
07:30 PM
NARRATIVE
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*** This is an Amended Report***
On 8/20/2025, 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 73 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.
Gate exit is not opening properly and the exit door in one of the residents rooms has the walkway dilapidated and needed to be repaired.
Each resident rooms were checked. R4 and R5s room have walls that needs to be repaired. R6 & R4s bottom mattress needs to be changed due to deterioration. Rooms 1, 2 & 3 doesn't have a chair, light and night stand. Pillows need to be updated. Bathroom was observed to be in disrepair, wall above the mirror has molds forming, trash bin does not have a lid and toilet paper holder needs to be repaired. Paper towels are not present in the bathroom.
Six resident records were reviewed. 5 out of 6 does not have an updated needs and services plan. R4 does not have a medical assessment (602) and functional capabilities assessment forms. R3 and R4 does not have an updated medical assessment, residents being 60 above. 6 out of 6 residents do not have a safeguards for property and valuables forms.
NAME OF LICENSING PROGRAM MANAGER:
Brenda Chan
NAME OF LICENSING PROGRAM ANALYST:
Grace Donato
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
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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California Health & Human Services Agency
California Department of Social Services
FACILITY EVALUATION REPORT
California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.
DEFICIENCIES
A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.
PLANS OF CORRECTION (POCs)
The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.
CORRECTION NOTIFICATION
The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.
CIVIL PENALTIES
The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.
PENALTY NOTICE GIVEN
The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.
APPEAL RIGHTS
The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.
AGENCY REVIEW
The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.
EMAIL REQUIREMENT
Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.
LIC809
(FAS) - (09/23)
Page:
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Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85068.3(a)
Modifications to Needs and Services Plan
(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above due to 5 out of 6 residents do not have an updated Needs and Services Plan which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to submit an updated needs and services plan signed by Administrator/Licensee and Resident by POC Due Date
Type A
Section Cited
CCR
80070(b)(8)
Client Records
(b) Each record must contain information including, but not limited to, the following: (8) Medical assessment, including ambulatory status, as specified in Section 80069.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, the licensee did not comply with the section cited above where R4 does not have a medical assessment (602A) on file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
08/21/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to submit a copy of R4's 602 to LPA by POC Due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
3
of
10
Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
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
1
2
3
4
Based on observation, the licensee did not comply with the section cited above due to walls deterioration in the room of R4 & R5, and bathroom wall above the mirror that has molds forming, toilet paper holder needs to be repaired which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/17/2025
Plan of Correction
1
2
3
4
Licensee to submit a plan to address the wall breakage and mould and to show photo proof of fixed/repaired walls. Licensee to submit by POC due date.
Type B
Section Cited
CCR
80087(c)
Building and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction.
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 one of the gate exits does not open properly and the passageway exit for the room of R4 and R5 had a broken walkway which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
09/17/2025
Plan of Correction
1
2
3
4
Licensee to submit a plan to address the repair of the gate and walkway and show photo proof once fixed. Licensee to submit by POC due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
4
of
10
Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80088(f)(1)
Fixtures, Furniture, Equipment, and Supplies
(f) Solid waste shall be stored, located and disposed of in a manner that will not transmit communicable diseases or odors, create a nuisance, or provide a breeding place or food source for insects or rodents. (1) All containers, including movable bins, used for storage of solid wastes shall have tight-fitting covers kept on the containers; shall be in good repair, shall be leakproof and rodent-proof.
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 the bathroom trash can not having a tight fitting cover which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee to provide a new trash bin that self closes or have a tight cover and show photo proog by POC due date.
Type B
Section Cited
CCR
85088(c)(1)
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. (1) An individual bed, except that couples shall be allowed to share one double or larger sized bed, maintained in good repair, and equipped with good bed springs, a clean mattress and pillow(s).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onobservation, the licensee did not comply with the section cited above due to the bed of R6 and R4 have old and dirty mattress which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
LIcensee to remove or change the secondary mattress and provide photo proof by POC Due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
5
of
10
Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(2)
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. (2) Bedroom furniture including, in addition to (c)(1) above, for each client, a chair, a night stand, and a lamp or lights necessary for reading.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based onobservation, the licensee did not comply with the section cited above due to all residents rooms doesnt have a lamp, rooms 1,2 & 3 doesnt have a chair & night stand which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee to provide lamps, chairs and nighstands for rooms and send photo proof by POC due date.
Type B
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 observtaions, pillows for all residents needs to be updated due to pillows being flat and not suitable for residents to get proper sleep which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee to provide pillows for residents and show photo proof by POC due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
6
of
10
Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85088(c)(4)(B)
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. (B) The use of common towels and washcloths shall be prohibited.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, there are no paper towels in the bathroom so that each resident doesn't have to use wash cloths when washing hands which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to provide paper towels to bathrooms and show photo proof by POC due date.
Type B
Section Cited
CCR
85068.4(e)
Acceptance and Retention Limitations
(e) The licensee shall ensure that the medical assessment for each client 60 years of age or older is updated at least annually and in accordance with the regulations addressing medical assessments in Residential Care Facilities for the Elderly (RCFE) [California Code of Regulations, Title 22, Sections 87458(b) and (c)].
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, R3 and R4 does not have a recent medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
LIcensee/Administrator shall submit a plan on when the residents will be scheduled for an annual medical assessment, and to keep records of said assessment by POC due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
7
of
10
Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069.2(b)
Functional Capabilities Assessment
(b) Assessment of the client's need for assistance shall include consideration of his/her physical condition affecting participation in his/her own care, including:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, R4 does not have a functional capabilities assessment on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to submit a functional capabilities assessment to LPA by POC due date.
Type B
Section Cited
CCR
80070(b)(14)
Client Records
(b) Each record must contain information including, but not limited to, the following: (14) An account of the client's cash resources, personal property, and valuables entrusted as specified in Section 80026.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on records review, all residents don't have an inventory of items that they own which need to be recorded in a form for Safeguards for Property/Valuables which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to fill up forms for each resident regarding their personal belongings and submit to LPA by POC due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
8
of
10
Document Has Been Signed on
08/20/2025 07:03 PM
- It Cannot Be Edited
Created By:
Grace Donato
On
08/20/2025
at
04:48 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:
08/20/2025
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 on records review, the emergency drill log only shows drill done on 8/20/2025, prior to that, no proof of other drills were dont aside from 8/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee/Administrator to submit a plan stating that emergency drills will be done every quarter and submit by POC due date
Type B
Section Cited
CCR
85079(f)
(f) Activities shall be encouraged through provision of the space, equipment and supplies specified in Sections 85087.2, 85087.3, and 85088(g).
Deficient Practice Statement
1
2
3
4
Based on interviews and observation, the television in the living room is not working and residents are complaining which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
08/27/2025
Plan of Correction
1
2
3
4
Licensee/Admininstrator to provide television activities such as channels were residents are able to watch shows they like. Licensee to submit proof by POC due 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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Grace Donato
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
Page:
9
of
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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:
CARE PLUS HOME
FACILITY NUMBER:
410508866
VISIT DATE:
08/20/2025
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Residents currently don't have a television with working channels as part of their activities.
LPA requested licensee to submit the following by 8/21/2025::
LIC 500 Personnel Report SHOWING HOURS WHEN ADMINISTRATOR IS ON SITE and exact shift times for staff.
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.
NAME OF LICENSING PROGRAM MANAGER
:
Brenda Chan
NAME OF LICENSING PROGRAM ANALYST
:
Grace Donato
LICENSING PROGRAM ANALYST SIGNATURE
:
DATE:
08/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/20/2025
LIC809
(FAS) - (06/04)
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