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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600162
Report Date: 11/17/2022
Date Signed: 11/17/2022 01:48:23 PM

Document Has Been Signed on 11/17/2022 01:48 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, RADIGONDEFACILITY TYPE:
740
ADDRESS:468 HAZEL AVENUETELEPHONE:
(650) 615-9937
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Florinda GuintoTIME COMPLETED:
02:00 PM
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LPA Audrey Jeung toured facility and grounds. On the main level, 3 bedrooms are occupied by 5 clients--one has a private bathroom--and 3 rooms are occupied by staff with one bed in each--one has a private bathroom. There is a common bathroom for clients and another common bathroom for staff. One of the staff rooms is behind the laundry room. In the backyard, there is a room used by staff that is on a level lower than the backyard. The licensee/administrator's room is level with backyard and accessed from backyard.
No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. 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. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 2 staff, plus the live-in family member. Criminal record clearances are maintained for staff and other non-clients. Current first aid training and health screenings for staff are reviewed. Charito Rafael is a certified RCFE administrator (x 10/23) that oversees facility operations.

The following information/forms are requested to be submitted to CCLD BY 12/1/22:
- Proof of current Liability Insurance
- Administrative Organization (LIC309)
- Designation of Facility Responsibility (LIC308)
- Personnel Report (LIC500)
- Proof of Control of property (IE: grant deed)

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page..
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
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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Document Has Been Signed on 11/17/2022 01:48 PM - It Cannot Be Edited


Created By: Audrey Jeung On 11/17/2022 at 12:14 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: ISMAELA'S HOME CARE, INC.

FACILITY NUMBER: 415600162

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 11/17/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff records, the licensee did not comply with the section cited above, as 2 out of 6 staff do not have health screening and TB test results on file, which poses a potential health, safety or personal rights risk to persons in care.
Health screening and TB test results for Staff MG and PM are not maintained.
POC Due Date: 12/01/2022
Plan of Correction
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Copies of current health screenings and TB test results for staff PM and MG will 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 Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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