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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600201
Report Date: 10/13/2023
Date Signed: 10/13/2023 03:19:59 PM


Document Has Been Signed on 10/13/2023 03:19 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:SPICE OF LIFE RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600201
ADMINISTRATOR:CRUZ, TERESITA B.FACILITY TYPE:
740
ADDRESS:419 TOPAZ STREETTELEPHONE:
(650) 364-4211
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:6CENSUS: 5DATE:
10/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ronel "Don" SangilTIME COMPLETED:
03:20 PM
NARRATIVE
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced 1 year annual inspection visit. LPA met with caregiver Don Sangil and explained the purpose of today's visit.

LPA toured the facility inside and outside with Don. This facility is is a one level facility. While touring the facility LPA tested the water in the common bathroom adjacent to the living room. Water is tested at 112F. Resident rooms observed maintained and have the required furniture and lighting. Residents have an adequate amount of linens and incontinence supplies, incidental supplies, as well as PPE as needed. Fire extinguisher is observed in the kitchen as charged. Tagged inspection is dated as 03/2023. Carbon monoxide detectors are present. Smoke detectors are observed through out facility. Resident bathroom is observed to be in good repair. Shower is observed as in working order with non-slip surfacing. 7 day non-perishable food supply and 2 day fresh food supply is observed as in place. Kitchen is observed as clean and in operating condition. Medications are stored and inaccessible in a locked in a medication closet in the kitchen. Medications are reviewed to be in place and accurately marked. Medication administration record is observed and is current. Centrally stored medication logs are in place and current. On site laundry is available and functioning.

5 staff records are reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, TB tests, training, CPR/First Aid cards, and personnel files are complete but additional training hours need to be completed as last training took place in February 2023. 2 Client records are reviewed and but is not current with physicians reports for dementia residents. Disaster drills are being conducted according to Don but it is not logged for review. Administrator certificate is observed as expired as of 07/2023 but application for renewal is pending after completing hours. Facility does not handle resident monies.

The following updated items are requested to be sent to the Department by 10/20/2023:
- Copy of administrator certificate renewal application
- LIC308
- LIC610E
- Facility liability insurance
- Infection control plan
- COVID mitigation plan LIC808
- Staff medication training

Report is reviewed with Don. Citations issued on following LIC809D.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
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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Document Has Been Signed on 10/13/2023 03:19 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: SPICE OF LIFE RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600201

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87705(c)(5)


This requirement is not met as evidenced by: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
Deficient Practice Statement
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Based on observation of R1 and R2 records, the licensee did not comply with the section cited above in 2 out of 2 residents with dementia do not have current appraisals and physicians reports, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2023
Plan of Correction
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Facility shall develop a plan to reassess residents with dementia and obtain current physician's reports. This plan shall be sent to the Department and followed up with evidence of the scheduling of such appointments and current plans and physicians reports.
Type A
Section Cited
HSC
1569.695(c)
(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
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Based on interview with staff, the licensee did not comply with the section cited, as no log is present for review and it is undetermined when such drill took place last, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2023
Plan of Correction
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Facility shall develop a plan to conduct a drill and document the drill indicating date, number of staff present conducting drill, and residents participating in the drill taking place. Plan shall indicated that such drill shall be conducted on a quarterly basis. This shall be sent to the Depratment for review.
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: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2023
LIC809 (FAS) - (06/04)
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