415600162-3-26-2024-14-AS-MHAN-D3QREA-20240326125714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600162
Report Date: 03/26/2024
Date Signed: 03/26/2024 06:28:27 PM

Document Has Been Signed on 03/26/2024 06:28 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:	ISMAELA'S HOME CARE, INC.		FACILITY NUMBER:	415600162
ADMINISTRATOR:	PEREDO, RADIGONDE		FACILITY TYPE:	740
ADDRESS:	468 HAZEL AVENUE		TELEPHONE:	(650) 615-9937
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 5	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Licensee, Florinda Guinto		TIME COMPLETED:	01:10 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 March 26, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with licensee, Florinda Guinto and explained the purpose of the visit. LPA toured facility and grounds. On the main level, 3 bedrooms are occupied by 5 residents--one has a private bathroom--and 2 rooms are occupied by staff with one bed in each--one has a private bathroom. There is a common bathroom for residents and another common bathroom for staff. In the backyard, there is a room used by staff and another room for the former administrator which is level with the backyard. No accessible bodies of water or fire safety hazards observed. Medications is stored appropriately and inaccessible to resident. Toxins and sharps are observed to be unlocked and accessible to residents. 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. There are 5 residents present, and 2 staff. LPA reviewed 4 resident and 4 staff files. Hot water temperature is measured at 108- 115 degrees F. Fire extinguisher was last checked on 5/9/2023. Charito Rafael is a certified RCFE administrator for the facility.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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 03/26/2024 06:28 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: ISMAELA'S HOME CARE, INC.	FACILITY NUMBER: 415600162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the storage room on the facility sketch behind the laundry has been altered to a staff room which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will remove all the furniture in the storage room by 3/27/2024 and provide photos to CCL. In addition, the administrator/licensee will submit a plan to CCL by 3/27/2024 to ensure compliance.

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed chemical stored underneath the sink were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff education. The administrator will provide proof that chemicals are locked and inaccessible to residents and will provide a copy of the staff in-service sign-in sheet.

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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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: ISMAELA'S HOME CARE, INC.	FACILITY NUMBER: 415600162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(b)(3)(B)

Personnel Records

(b) Personnel records shall be maintained for all volunteers and shall contain the following: (3) For volunteers that are required to be fingerprinted pursuant to Section 87355, Criminal Record Clearance: (B) Documentation of either a criminal record clearance or a criminal record exemption as required by Section 87355(e). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 4 staff did not have criminal clearance record in the personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 4/8/2024.

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	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able provide proof that drills were conducted in 2023 to present which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance and on the plan, it shall indicate when the drills will be conducted. The administrator/licensee will submit a copy of the plan to CCL by 4/8/2024.

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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/26/2024 06:28 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: ISMAELA'S HOME CARE, INC.	FACILITY NUMBER: 415600162
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

This requirement is not met as evidenced by:87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed fruit flies in the resident bathroom, dining room, kitchen, hallway, etc. and the overall facility (resident rooms, staff rooms, kitchen, dining room) appeared to be cluttered with files, paperwork, clothes, fruits, plastic bottles, recycle bottles, food items, etc. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/08/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure facility is clean and safe for residents in care. The administrator will provide photos of the facility and a copy of the plan to CCL 4/8/2024.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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: ISMAELA'S HOME CARE, INC.	FACILITY NUMBER: 415600162
	VISIT DATE: 03/26/2024

NARRATIVE

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The following information/forms are requested to be submitted to CCLD BY 3/28/24:
- A written letter from the Licensee appointing Charito Rafael as the administrator
- Proof of the renewal Administrator Certification application submitted for Charito Rafael
- Proof of current Liability Insurance
- Designation of Facility Responsibility (LIC308)

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with licensee. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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