<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600257
Report Date: 05/04/2022
Date Signed: 05/04/2022 05:14:23 PM


Document Has Been Signed on 05/04/2022 05:14 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:SUNVALLEY CHATEAU PACIFICAFACILITY NUMBER:
415600257
ADMINISTRATOR:CHRISTIAN TOPIRCEANUFACILITY TYPE:
740
ADDRESS:689 LADERA WAYTELEPHONE:
(650) 355-8948
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY:16CENSUS: 11DATE:
05/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Cristian TopirceanuTIME COMPLETED:
12:00 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 5/4/2022, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA met with administrator and explained the purpose of the visit. LPA was not screened by the entrance.
LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. There are 11 residents at the facility (9 female and 2 male). PPE supply and the environmental cleaning supply are adequate, all trash cans are observed to be equipped with foot operated lids.

During the inspection, LPA observed 3 residents in the living room without face covering, however, they were 6" apart from each other. The outdoor patio is designated as the visitation area.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, a comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

Based on the documentation provided, it revealed that facility stopped properly screening visitor's for COVID-19 since 3/22/22.

During the facility tour, LPA did not observed any COVID-19 signs around the facility and there was no hand-washing instructions posted in any of the bathrooms.

LPA requested for the following documents to be submitted to the Regional Office by 5/9/22:
- Updated Emergency Disaster LIC610E
- Affidavit Regarding Client/ Resident Cash Resources LIC400
- A copy of Administrator's Certificate
- Control of Property
- LIC500

Deficiency is observed and cited on a LIC 809Ds. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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 2


Document Has Been Signed on 05/04/2022 05:14 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: SUNVALLEY CHATEAU PACIFICA
FACILITY NUMBER: 415600257

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above as LPA was not screened at the entry point and the facility stopped properly screen visitors for COVID-19 since March 22,2022 In addition,LPA did not observed any COVID-19 signs posted around the facility and hand washing instructions by the sinks which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
1
2
3
4
Facility will restart the visitor screening protocols today and will send proof of such screening to CCL by 5/18/2022.
Facility will post COVID-19 signs around the facility and hand washing instructions by each hand washing station and send proof of all the postings to CCL by 5/18/2022
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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2