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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600158
Report Date: 04/08/2024
Date Signed: 04/08/2024 01:54:20 PM


Document Has Been Signed on 04/08/2024 01:54 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:OUR HOUSEFACILITY NUMBER:
415600158
ADMINISTRATOR:PAGADOR, LIONELFACILITY TYPE:
740
ADDRESS:1916 SHOREVIEW AVENUETELEPHONE:
(650) 401-7175
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ludiben Balico and Ursula PagadorTIME COMPLETED:
02:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, including, detached storage shed, which is locked. There are no accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Hot water temperature is tested at 115 degrees in clients' bathroom. Food supply and first-aid kit are inspected and complete. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records, provided by pharmacy. An updated Disaster and Mass Casualty Plan is posted.

Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Lionel Pagador is a certified RCFE administrator that oversees facility operations.

The following form is requested to be updated and returned to CCL by 4/22/24:
• LIC 500 Personnel Report

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Advisory Notes for technical violations to be corrected--3 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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Document Has Been Signed on 04/08/2024 01:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: OUR HOUSE
FACILITY NUMBER: 415600158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff record review, the licensee did not comply with the section cited above, as there is no evidence that all staff have received at least 4 hours of training on hospice care, restricted health conditions and postural supports.
This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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All staff shall receive at least 4 hours of training on hospice care, restricted health conditions and postural supports. Proof of correction to be sent to CCLD 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/08/2024 01:54 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: OUR HOUSE
FACILITY NUMBER: 415600158

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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2
3
4
Type B
Section Cited
HSC
1569.695(f)(2)(D)
Other Provisions
(f) A facility shall have both of the following in place: (2) A set of keys available to facility staff on each shift for use during an evacuation that provides access to all of the following: (D) All facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.

This requirement is not met as evidenced by:
Deficient Practice Statement
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(A) All occupied resident units.
(B) All facility vehicle
(C) All facility exit doors.
Based on observation, the licensee did not comply with the section cited above, as an emergency set of keys is not maintained, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/22/2024
Plan of Correction
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An emergency set of keys will be maintained and include all occupied resident units, all facility vehicles, all facility exit doors, all facility cabinets and cupboards or files that contain elements of the emergency and disaster plan, including, but not limited to, food supplies and protective shelter supplies.
Proof of correction to be sent to CCLD 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
LIC809 (FAS) - (06/04)
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