415201955-8-31-2019-14-AS-DPAO-BFKW4F-20190831165727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415201955
Report Date: 08/31/2019
Date Signed: 08/31/2019 04:57:37 PM

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:	SENIORS WITH GRACE CARE HOME		FACILITY NUMBER:	415201955
ADMINISTRATOR:	MANUEL, GRACE		FACILITY TYPE:	740
ADDRESS:	167 ALAMEDA DE LAS PULGAS		TELEPHONE:	(650) 369-5070
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	6	CENSUS: 5	DATE:	08/31/2019
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Grace Manuel, Administrator		TIME COMPLETED:	05:15 PM

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 08/31/19 at 03:32 PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted an unannounced required one year inspection and was greeted by caregiver (S1) Fjoewel Santos. LPA requested S1 to contact Administrator (ADM) Grace Manuel to come to the facility for the required one year inspection. LPA explained the purpose of the visit with ADM. At 03:43 PM, LPA inspected the facility inside and outside. Pathways were observed to be free of obstruction and fire hazards. The facility's fire clearance was approved for 6 non-ambulatory residents which includes Hospice Waiver for two (2) residents. Centrally stored medications were locked in a cabinet above the wall next to the kitchen. Sharp objects were locked in the kitchen drawer next to the stove. Toxic chemicals were locked in the laundry room. At 04:00 PM, LPA observed there was at least 7 days of nonperishable and 2 days of perishable foods. Facility room temperature was maintained at 72 degrees Fahrenheit. Hot water temperature was measured at 105.5 degrees Fahrenheit in the resident's bathroom. Resident's bathrooms have grab bars inside the shower and non-skid mats.The facility has trained staff in Dementia Care, Medication, and Basic Training. Last Fire drill was conducted on 05/01/19. Fire extinguisher was fully charged and last inspected on 02/29/19. Smoke and Carbon monoxide detectors were operational. Continued on next page LIC 809-C

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 363-5470
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2019

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 4

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: SENIORS WITH GRACE CARE HOME	FACILITY NUMBER: 415201955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/20/2019 Section Cited	1 2 3 4 5 6 7	87555 General Food Service Requirements (b)(21) ...Freezers of adequate size shall be maintained at a temperature of 0 degrees F (-17.7 degrees C)...They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Garage freezer had two to three inches of frost on each shelves with frost bitten meat packages inside which posed a potential Health & Safety risk to residents in care	8 9 10 11 12 13 14
Type B 09/20/2019 Section Cited	1 2 3 4 5 6 7	87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Emergency/Disaster Plan (LIC610E) was missing and not posted near a Lan line phone which posed a potential Health & Safety risk to residents in care	8 9 10 11 12 13 14	Plan.

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: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 363-5470
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2019

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: SENIORS WITH GRACE CARE HOME	FACILITY NUMBER: 415201955
	VISIT DATE: 08/31/2019

NARRATIVE

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At 04:15 PM, LPA reviewed three (3) staff and three (3) resident files. Staff had criminal record clearances to work and are associated to the facility. Residents records contain Admission Agreements, Physicians' reports, Consent forms, Personal rights, medical assessments, ID/Emergency informations, Needs and Services plans/Appraisals. The facility serves residents with Dementia. The facility has potentially dangerous objects locked and inaccessible to residents in care. The facility has auditory signals on each sliding door in the resident's room. Staff at the facility has the required Dementia training.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 09/20/19:
· LIC500- Personnel Report
· LIC308- Designation of Facility Responsibility
· LIC610E- Emergency/Disaster Plan 2019
· Evidence of Liability Insurance 2019

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12 month period may result in civil penalties.

LPA observed the following deficiencies during inspection:

Garage freezer had two to three inches of frost on each shelves with frost bitten meat packages inside
Emergency/Disaster Plan (LIC610E) was not posted near a Lan line phone
Last Fire Drill was conducted on 10/22/2018

Exit interview conducted, appeal rights copy of this report provided to ADM.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 363-5470
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2019

LIC809 (FAS) - (06/04)

Page: 2 of 4

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: SENIORS WITH GRACE CARE HOME	FACILITY NUMBER: 415201955
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/31/2019

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/20/2019 Section Cited	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (k)(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Last Fire Drill was conducted on 10/22/2018 which posed a potential Health & Safety risk to residents in care	8 9 10 11 12 13 14	months in compliance with Section 87705(k)(3) of Title 22 regulations.
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 363-5470
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2019

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2019

LIC809 (FAS) - (06/04)

Page: 4 of 4