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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600099
Report Date: 11/15/2024
Date Signed: 11/15/2024 01:00:10 PM

Document Has Been Signed on 11/15/2024 01:00 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:LA SALETTE HOME, LTD. IIIFACILITY NUMBER:
415600099
ADMINISTRATOR/
DIRECTOR:		MELANIE BUMANGLAGFACILITY TYPE:
735
ADDRESS:274 ST. CATHERINE DRIVETELEPHONE:
(650) 993-4137
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 4DATE:
11/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Flordeliza RabinoTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On November 15, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Caregiver, Flordeliza Rabino and explained the purpose of the visit.

LPA toured the facility inside and outside including all of client rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two story facility; client bedrooms, kitchen, common area, bathrooms, etc. on the second floor, and staff bedroom, garage, and one client room on the first floor. All residents were either at their day programs or out of the facility.

Second floor living room and dining room was observed to be clean, free from tripping hazards and odor-free. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA toured kitchen and observed two day perishable and seven day non-perishables. Sharps, chemicals and medications were observed to be locked an inaccessible to clients. LPAs observed three client bedrooms; two shared rooms and one single-private room. All rooms were observed to be in good repair with required furniture. Two full bathrooms were observed on the second floor; equipped with liquid soap and non-skid mats. LPA advised Water temperature throughout the facility measured between 127.7-129.3 degrees F. Extra linen was observed to be present.

LPAs toured the first floor; garage, resident room, a staff room and a bathroom. Washer and dryer were in good repair. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current as of April 2024. Emergency drills are logged and done quarterly. LPAs reviewed 4 client records and 4 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiencies of the California Code of Regulations, Title 22 are cited on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Caregiver and a copy is provided
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2024
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 3
Document Has Been Signed on 11/15/2024 01:00 PM - It Cannot Be Edited


Created By: Komal Charitra On 11/15/2024 at 12:48 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: LA SALETTE HOME, LTD. III
FACILITY NUMBER: 415600099

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations water temperature to be between 127.7-129.3 throughout the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/16/2024
Plan of Correction
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Facility shall ensure water tempertaure is between 105-120 degrees F and provide LPA photos/video to show that the water temperature is between regulatory requirements.
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:April Cowan
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/15/2024


LIC809 (FAS) - (06/04)
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