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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600219
Report Date: 09/17/2024
Date Signed: 09/17/2024 04:56:43 PM


Document Has Been Signed on 09/17/2024 04:56 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:SONAS HOMEFACILITY NUMBER:
415600219
ADMINISTRATOR:RYAN, EVELYN B.FACILITY TYPE:
740
ADDRESS:886 GULL AVENUETELEPHONE:
(650) 577-9909
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:6CENSUS: 4DATE:
09/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Phillip EleraTIME COMPLETED:
12:30 PM
NARRATIVE
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On September 17, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Criselda Bautista and LPA explained the purpose of the visit. Lead caregiver, Phillip Elera arrived shortly thereafter and assisted with the visit.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, garage and backyard. This is a single story home with 5 resident bedrooms(4 private and 1 semi-private), 2 full bathrooms, and 1 staff room. The indoor and outdoor passageways were free of obstruction. 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 108-112 degrees F.

Central stored medication were observed to be locked and inaccessible to residents. Food supplies were observed to be adequate,

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced Oct 26, 2023. Fire drill was last conducted on August 2024.

A review of (4) 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 document is requested submitted to CCL by 9/18/2024
- Administrator Certification

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 the lead caregiver. A copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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 09/17/2024 04:56 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SONAS HOME
FACILITY NUMBER: 415600219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

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 in as 4 out of 4 residents did not have an updated reappraisal needs/service plans which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The administrator will provide a copy of the updated appraisal needs and service plans for all the residents and provide a copy to CCL by 9/24/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/17/2024 04:56 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: SONAS HOME
FACILITY NUMBER: 415600219

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(a)


This requirement is not met as evidenced by:87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as resident #1 (R1)'s Physician's Report (LIC602) in 2024 was not signed by the physician which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The administrator will provide a copy of the signed and completed LIC 602 to CCL by 9/24/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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