415600219-10-10-2023-14-AS-MHAN-CWGRMN-20231010130902

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600219
Report Date: 10/10/2023
Date Signed: 10/10/2023 06:35:45 PM

Document Has Been Signed on 10/10/2023 06:35 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:	SONAS HOME		FACILITY NUMBER:	415600219
ADMINISTRATOR:	RYAN, EVELYN B.		FACILITY TYPE:	740
ADDRESS:	886 GULL AVENUE		TELEPHONE:	(650) 577-9909
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	6	CENSUS: 4	DATE:	10/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Administrator, Evelyn Ryan		TIME COMPLETED:	01:20 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 October 10, 2023 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Rhealynne Cabarlez and Phillip Elera and LPA explained the purpose of the visit. Caregiver Rhealynne contacted the administrator via phone of LPA's visit and administrator arrived shortly thereafter and assisted with the inspection. LPAs toured the facility inside and outside including the bedrooms (4 private rooms, 1 semi-private room and 1 staff room), 2 full- bathrooms, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 102- 105 degrees F. Central stored medication were observed to be locked and inaccessible to residents. Food supplies were observed to be adequate, At 11:08 am, LPA observed toxins and sharps objects in the kitchen were unlocked. LPA reviewed 3 staff training records and observed 2 out of 3 were adequate, and staff #1(S1) was missing some records. According to administrator that S1 has completed all the required training but some of the records are kept at the administrator's residence. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced Oct 13, 2022. Fire drill was last conducted on August 2023.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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 10/10/2023 06:35 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: SONAS HOME	FACILITY NUMBER: 415600219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 and interview, at 11:08am LPA observed sharps and chemicals are not locked, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/11/2023
	Plan of Correction
1 2 3 4	The administrator will submit a plan of correction to ensure all chemicals and sharps are locked at all times and inaccessible to residents in care to CCL by 10/11/2023 and will provide a copy of the in-service sign-in sheet.

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/10/2023 06:35 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: SONAS HOME	FACILITY NUMBER: 415600219
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(e)(3)

Other Provisions

(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record reviews, the licensee did not comply with the section cited above as the administrator was not able to provide proof that training was completed for staff. According to administrator, training was completed but all the sign-in sheets are kept at the administrator's personal residence which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2023
	Plan of Correction
1 2 3 4	The administrator will submit a copy of all training records to CCL by 10/17/2023 and will submit a plan to ensure all records are maintained at the facility.

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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: SONAS HOME	FACILITY NUMBER: 415600219
	VISIT DATE: 10/10/2023

NARRATIVE

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Staff members at the facility were fingerprint cleared and associated to the facility.

LPA reviewed residents and staff records. Resident records contained admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP, etc.

Staff files contained personnel records, health screening, COVID-19 vaccination card, Abuse Statement, First Aide and CPR, Criminal Record Statement.

LPA reviewed P & I records and observed Record of Client's/ Resident's Safeguarded Case Resources (LIC 405) and receipts for 3 residents.

During today's inspection, there were 2 residents present and 2 were attending the adult day program.

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 caregiver, Phillip Elera. A copy of this report and 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: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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