415201849-9-26-2024-14-AS-KJAN-D8SVSX-20240904164215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415201849
Report Date: 09/04/2024
Date Signed: 09/26/2024 03:22:56 PM

Document Has Been Signed on 09/26/2024 03:22 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 09/19/2024 09:41 PM

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

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On September 26, 2024 at 2:35 PM, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra conducted an unannounced visit to deliver a copy of amended LIC809-C report. LPAs met Natvidad Garcia, caregiver and Leticia Devijo, caregiver and explained the purpose of the visit. On September 04, 2024, Licensing Program Analysts (LPAs) Kiran Jain and John Calandra arrived at the facility at 09:40 AM to conduct the Annual 1-year required inspection. LPAs Jain and Calandra met with Emma Advincula, Caregiver, and explained the purpose of the visit. Cyndi Advincula, Administrator joined the visit later. LPAs Jain and Calandra toured the physical plant. This is a single-story building with 8 bedrooms, 2 bathrooms, living room, and kitchen with dining. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and last serviced on April 2022. The smoke detector and carbon monoxide detector were fully operational. All rooms were observed to be clean with sufficient furniture and lighting. The hot water temperature in the bathroom sink faucet was measured at 112.3°F. Sharp objects, detergents, poisons, and soap were observed to be accessible to persons in care. In the presence of the LPAs, they were locked and are no longer accessible to persons in care. The kitchen sink water temperature was measured at 113.8°F. No expired food items were observed. The facility had the required 7-days of non-perishables and 2-days of perishables. LPA reviewed five resident records and five staff records. All were observed to be complete. The client’s medications are securely stored in a locked cabinet. Medication administration records (MARs) were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be sufficiently stocked.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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 10

Document Has Been Signed on 09/04/2024 04:42 PM - It Cannot Be Edited

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: EAST WEST CARE REDWOOD CITY II	FACILITY NUMBER: 415201849
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	87411(f) Personnel Requirements: Based on record review, the licensee did not comply with the section cited above in 3 out of 5 staff records which didn't have TB results, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by 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.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 2 of 10

Document Has Been Signed on 09/04/2024 04:42 PM - It Cannot Be Edited

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: EAST WEST CARE REDWOOD CITY II	FACILITY NUMBER: 415201849
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	1569.695(c) Other Provisions: Based on interview with the Administrator, the licensee did not comply with the section cited above in 1 out of 1 emergency drill logs for 2024, which are not present in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 09/11/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 3 of 10

Document Has Been Signed on 09/04/2024 04:42 PM - It Cannot Be Edited

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: EAST WEST CARE REDWOOD CITY II	FACILITY NUMBER: 415201849
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

87355(e)(2) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	87355(e)(2) Criminal Record Clearance: Based on record review, the licensee did not comply with the section cited above in 1 out of 5 staff who have criminal record clearance but are not associated with the facility as of 09/04/2024, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/05/2024
	Plan of Correction
1 2 3 4	Administrator/Licensee to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 per day.

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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 9 of 10

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: EAST WEST CARE REDWOOD CITY II	FACILITY NUMBER: 415201849
	VISIT DATE: 09/04/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On September 26, 2024 at 2:35 PM, Licensing Program Analysts (LPAs) Kiran Jain and Komal Charitra conducted an unannounced visit to deliver a copy of amended LIC809-C report. LPAs met Natvidad Garcia, caregiver and Leticia Devijo, caregiver and explained the purpose of the visit.

The following updated forms are requested to be submitted to CCLD:
· LIC 500: Personnel Report

LPAs received current liability insurance via email during the visit along with the current Administrator certificate.

A Civil Penalty of $500 ($100/day x 5 days) for having a staff member not associated to the facility.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Cyndi Advincula, Administrator and a copy of this report along with appeal rights was left at the facility.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran Jain	TELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

Page: 10 of 10