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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600162
Report Date: 03/05/2025
Date Signed: 03/05/2025 04:27:49 PM

Document Has Been Signed on 03/05/2025 04:27 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:ISMAELA'S HOME CARE, INC.FACILITY NUMBER:
415600162
ADMINISTRATOR/
DIRECTOR:		CHARITO RAFAELFACILITY TYPE:
740
ADDRESS:468 HAZEL AVENUETELEPHONE:
(650) 615-9937
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
03/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Licensee, Florinda GuintoTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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On March 6, 2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with licensee, Florinda Guinto and explained the purpose of the visit. The administrator, Charito Rafael arrived at the end of the inspection.

The Licensee provide a toured of the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort.

On the main floor, LPA observed total of 5 bedrooms (2 staff rooms and 3 shared resident rooms) and on the lower level, LPA observed a big bedroom with a bath/shower room inside.

Hot water temperature in the kitchen, and bathroom was measured at 105-136 degree F. Extra linen was present. Medications were locked and inaccessible to residents. 2 days for perishables and & 7 days non-perishable were observed to be present.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

The following information/form is requested to be submitted to CCLD BY 3/7/2025:

- Proof of current Liability Insurance

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 and administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
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 03/05/2025 04:27 PM - It Cannot Be Edited


Created By: Murial Han On 03/05/2025 at 11:21 AM
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: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above the hot water temperatures in the resident's bathroom were measured at 136 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2025
Plan of Correction
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The administrator/licensee will submit a plan in writing to ensure that hot water temperature is within the range of 105-120. The administrator/Licensee will submit a copy of the plan to CCL by 3/6/2025
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:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/05/2025 04:27 PM - It Cannot Be Edited


Created By: Murial Han On 03/05/2025 at 11:21 AM
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: 03/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 2 staff members did complete the annual required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2025
Plan of Correction
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The administrator/licensee will provide a plan to ensure all staff will complete the required training and the administrator/licensee will provide a copy of the training records for the 2 staff members by 3/13/2025 as well as the plan of correction.
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:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2025


LIC809 (FAS) - (06/04)
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