415600197-10-14-2023-14-AS-JLUD-CWLU8Z-20231014152218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600197
Report Date: 10/14/2023
Date Signed: 10/14/2023 03:22:27 PM

Document Has Been Signed on 10/14/2023 03:22 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	FRIENDLY ACRES ELDERLY HOME		FACILITY NUMBER:	415600197
ADMINISTRATOR:	FRANCO, KALAITA TAVAKE		FACILITY TYPE:	740
ADDRESS:	3526 PAGE STREET		TELEPHONE:	(650) 369-4503
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94063
CAPACITY:	6	CENSUS: 3	DATE:	10/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Licensee Kalaita Franco		TIME COMPLETED:	03:30 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	Licensing program Analyst (LPA) Jason Lund arrived unannounced annual/required inspection. LPA Lund met with Licensee Kalaita Franco explained the purpose of the visit. Census:3 LPA Lund and Licensee Kalaita Franco toured/inspected the facility with licensee. Each room is equipped with a bed for each resident working lights and a night stand. Bathroom next to the staff room & Room 1 was observed. Room 2 and 3 and bathroom were observed. Facility has functioning smoke detectors/carbon monoxide detectors in the hallway, and in each resident room. Facility has a written emergency disaster plan. All outdoor and indoor passageway are free and clear of obstruction. All toilets and showers have grab bars installed for residents' use. No pools or bodies of water were observed during today's visit. LPA observed at least one week of nonperishable and two (2) days of perishable foods. Toxic chemicals are stored away in the garage. Centrally stored medications are locked in two kitchen cabinet. Licensee stated that there are no Medication Administration Record Sheet for all three residents in care. Licensee stated there are no firearms or ammunition at the facility. Fire extinguishers located in the family room and living rooms, inspected on 11/15/2018 and are out of regulation.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME	FACILITY NUMBER: 415600197
	VISIT DATE: 10/14/2023

NARRATIVE

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There are no files to review for residents 1 through 3 to review. All residents in care are missing information, which is required under title 22 to be kept at the facility. Licensee Kalaita Franco has not renewed Administrator certificate since 2018. CPR has not been renewed since 2018 for 1 Staff & Licensee Kalaita Franco. The two staff on hand today have criminal background checks, but do not have staff files for licensing to review.

LPA Lund interviewed all three residents in care and stated that there needs are being taken care of.

The following deficiencies were observed (see LIC 809-D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted with Licensee Kalaita Franco and appeal rights provided.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2023 03:22 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME	FACILITY NUMBER: 415600197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(a)

This requirement is not met as evidenced by:(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
	Deficient Practice Statement
1 2 3 4	Based on observation and interview with, the licensee did not comply with the section cited above in 3 out of 3 residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licensee with get residents records in order and notify LPA Lund.

Type B

Section Cited

HSC

80075(f)

This requirement is not met as evidenced by: (f) Staff responsible for providing direct care and supervision shall receive training in first aid from persons qualified by agencies including but not limited to the American Red Cross.
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review, the licensee did not comply with the section cited above in that the two staff did not have current CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Staff will get CPR training and email LPA Lund

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: Anthony Perez	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/14/2023 03:22 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME	FACILITY NUMBER: 415600197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87405(a)

This requirement is not met as evidenced by: 87405(a) Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator.
	Deficient Practice Statement
1 2 3 4	Based on observation,interview and record review, the licensee did not comply with the section cited above in that Licensee Kalita Franco had not renewed Administrator certificate since 2018,which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	Licensee with start training to get Administrator certificate.

Type A

Section Cited

CCR

87202(a)

This requirement is not met as evidenced by:(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:
	Deficient Practice Statement
1 2 3 4	(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: Based on observation, the licensee did not comply with the section cited above in 2 out of 2 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/16/2023
	Plan of Correction
1 2 3 4	Licensee will contact Fire Extinguisher company and get two new Fire Extiguisher and notify LPA Lund

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: Anthony Perez	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 10/14/2023 03:22 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FRIENDLY ACRES ELDERLY HOME	FACILITY NUMBER: 415600197
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)

This requirement is not met as evidenced by: (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview and record review, the licensee did not comply with the section cited above in the two staff didn' have personnel records which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/30/2023
	Plan of Correction
1 2 3 4	Licesness with have personnel records for staff for review for CCL by POC date

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: Anthony Perez	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Jason Lund	TELEPHONE: (916) 223-6752
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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