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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 410508909
Report Date: 05/22/2024
Date Signed: 05/22/2024 05:07:04 PM

Document Has Been Signed on 05/22/2024 05:07 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 - ACACIA AVENUE HOMEFACILITY NUMBER:
410508909
ADMINISTRATOR/
DIRECTOR:		SURDEL, PHILFACILITY TYPE:
735
ADDRESS:453 ACACIA AVENUETELEPHONE:
(650) 589-9107
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
05/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:House Manager, Harry SmithTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On May 22, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with house manager, Harry Smith and explained the purpose of the visit. The administrator, Phil Surdel arrived shortly thereafter and assisted with the rest of the inspection.

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 one shared resident bedroom with a full bathroom, one private room and one community full bathroom. The lower level has a living room, the laundry room, three private rooms and one full bathroom. .

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. Facility exits are equipped with audible alarms. 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: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2024
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 - ACACIA AVENUE HOME
FACILITY NUMBER: 410508909
VISIT DATE: 05/22/2024
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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 (6) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

A review of 5 P & I was conducted.

The following documents were requested submitted to CCL by 5/28/24:
- Control of Property, LIC 308, LIC 500, and Surety Bond

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: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 05/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/22/2024 05:07 PM - It Cannot Be Edited


Created By: Murial Han On 05/22/2024 at 11:41 AM
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 - ACACIA AVENUE HOME
FACILITY NUMBER: 410508909

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(a)(1)


This requirement is not met as evidenced by: 80069 Client Medical Assessment
(1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as one out six resident medical assessment was completed in 2021 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2024
Plan of Correction
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The administrator will provide a copy of the updated medical assessment to CCL by 6/4/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2024


LIC809 (FAS) - (06/04)
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