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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600099
Report Date: 12/08/2022
Date Signed: 12/19/2022 11:14:52 AM

Document Has Been Signed on 12/19/2022 11:14 AM - 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:LA SALETTE HOME, LTD. IIIFACILITY NUMBER:
415600099
ADMINISTRATOR:MELANIE BUMANGLAGFACILITY TYPE:
735
ADDRESS:274 ST. CATHERINE DRIVETELEPHONE:
(650) 993-4137
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 5DATE:
12/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Caregiver, Rosemarie PalaoagTIME COMPLETED:
02:30 PM
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On 12/8/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by staff-in- charge, Rosemarie Palaoag who called the administrator and left a message informing LPA's visit. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed. Facility has 1 private room and 2 shared rooms upstairs for residents and 2 private rooms downstairs- 1 for resident and 1 for staff. LPA observed beds in shared rooms to be 6" apart. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is posted by the hand washing stations.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

There are 3 residents present during the inspection and 2 are at the day program.

During the inspection, LPA also observed facility was not able to provide documentation of the daily COVID-19 temperature and symptom screening checks.. According to staff, this was stopped in 2021.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2022
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: LA SALETTE HOME, LTD. III
FACILITY NUMBER: 415600099
VISIT DATE: 12/08/2022
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Deficient is observed doing today's visit and will be cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

LPA requested for a copy of current administrator certification to be submitted to CCL by 12/15/2022.

This report is reviewed and discussed with staff; a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/19/2022 11:14 AM - It Cannot Be Edited


Created By: Murial Han On 12/08/2022 at 01:50 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: LA SALETTE HOME, LTD. III
FACILITY NUMBER: 415600099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80072(a)(2)
Personal Rights
(a) Each client shall have personal rights including: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as the facility failed to conduct the daily COVID-19 screening (temperature and symptom checks) for staff and residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/09/2022
Plan of Correction
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The administrator and/or licensee shall resume the daily COVID-19 screening of temperature and symptoms for staff and residents immediately. The administrator/licensee will educate staff on the importance of conducting the daily COVID-19 screening and will develop a plan to ensure this is done on a daily basis. The administrator/licensee will provide a copy of such plan, a signed statement ensuring this task will be done on a daily basis, and a copy of the in-service record to CCL by the plan of correction due date 12/9/2022.
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: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2022


LIC809 (FAS) - (06/04)
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