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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600310
Report Date: 11/04/2021
Date Signed: 11/04/2021 12:34:22 PM

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:CELESTE CARE HOMEFACILITY NUMBER:
415600310
ADMINISTRATOR:GALANG, TERESITA M.FACILITY TYPE:
740
ADDRESS:1714 CELESTE DRIVETELEPHONE:
(650) 356-0902
CITY:SAN MATEOSTATE: CAZIP CODE:
94402
CAPACITY:6CENSUS: 4DATE:
11/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Necia Conde TIME COMPLETED:
01:15 PM
NARRATIVE
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On November 4, 2021, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced annual inspection. Upon arrival, LPA did not observe any COVID-19 signage at the front door. LPA was greeted by one of the Administrator, Necia Conde. LPA Charitra explained the purpose of the visit. LPA was not screened at the front entrance and the Administrator was not able to provide the daily visitor screening log documentation.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not reviewed: entry procedures, resident and staff daily monitoring records, visitor screening log, COVID-19 signage at the front door and throughout facility. LPA spoke to the administrator in regards to adding more COVID signage and to start documenting temperatures for visitors, residents, and staff.

There were two bathrooms observed during the tour; both equipped with liquid hand soap and paper-towels. LPA advised Administrator to cover the trash bins with lids and to not keep cloth towels in the bathrooms or kitchen. There are 6 bedrooms in total; 4 single rooms which are occupied at this time, a semi-private room (Room #5), and a staff room. Resident room #5 was observed to now be used as a staff room because it is vacant.

Extra linen was observed to be present. PPE supply and the environmental cleaning supply are adequate. Medications, toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed.

The following forms are requested to be submitted to LPA by 11/11/2021:
-LIC610E Emergency Disaster Plan
-LIC308 Desgination of Administrative Responsibility
-LIC309 Administrative Organization
-Administrator Certificate

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. 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) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2021
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: CELESTE CARE HOME
FACILITY NUMBER: 415600310
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by: Facility was unable to provide screening log documentation for visitors, staff, and residents; Facility failed to post COVID-19 signage at the front door and in the living/dining area
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log; the facility failed to post COVID-19 signage in the living room, dining room, and the front door; Facility did not cover the bathroom trash cans with lids
POC Due Date: 11/11/2021
Plan of Correction
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The Administrator and/or designee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening process for visitors, residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done. Administrators will start implementing documenting practices that were taken at the beginning of the year and ensure staff are aware of the practices.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2021
LIC809 (FAS) - (06/04)
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