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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600310
Report Date: 08/05/2022
Date Signed: 08/05/2022 12:23:21 PM


Document Has Been Signed on 08/05/2022 12:23 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: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:
08/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Administrator, Ivy LagoneroTIME COMPLETED:
12:45 PM
NARRATIVE
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On August 5, 2022, Licensing Program Analysts (LPA) Komal Charitra and Kevin Varilla conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID-19 signage posted on the front entrance. LPAs met with Administrator, Ivy Lagonero and explained the purpose of the visit. LPAs were screened at entry point however did not sign in. Administrator was able to provide screening log documentation for residents but not staff members.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 resident rooms, 2 staff rooms, and 2 full bathrooms. The 4 residents rooms were observed to be private rooms. LPAs observed the bathrooms to be equipped with liquid soap, paper towels, hand washing signs, however LPA advised Administrator to cover trash cans with lids, remove bar soaps, remove hand/bath towels, and cover tooth brushes with caps. Extra linen was observed to be present.

Infection control practices are not reviewed: entry procedures, staff daily monitoring records for staff and visitor screening and sign in log.

LPAs toured the living room and dining room and observed it to be clear from any tripping hazards. COVID-19 signs were observed to be posted throughout the facility. A comfortable temperature is maintained and lighting is sufficient for comfort. LPAs toured the kitchen and observed 2 day perishable and 7 day non-perishable. Medications and sharps were observed to be stored appropriately and inaccessible to residents. LPA advised Administrator to remove hand-towels from the kitchen. First aid kit was observed to be completed.

LPAs toured the garage and observed washer and dryer to be in good repair. 30-day PPE supply and emergency food supply was present. Toxins were locked and stored appropriately.

CONT. to 809C
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
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 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: CELESTE CARE HOME
FACILITY NUMBER: 415600310
VISIT DATE: 08/05/2022
NARRATIVE
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LPA requests the following forms to be sent to CCLD by 8/12/22:
  • LIC308 Designation of Administrative Organization
  • LIC500 Personnel Report
  • LIC610E Emergency Disaster Plan
  • Administrator Certificate


87468.1(a)(2)- Personal Rights of Residents in All Facilities- This is the second repeat violation within 12 months. Facility was cited on 11/4/2021 under section 87468.1(a)(2).

$1,000 CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION WITHIN 12 MONTHS.

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.

Report is reviewed with Administrator and a copy is provided with appeals rights. In addition, Civil penalty is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/05/2022 12:23 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: CELESTE CARE HOME
FACILITY NUMBER: 415600310

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2022
Section Cited

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87468.1 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
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Based on observation, facility failed to maintain a visitor sign in log; facility failed to provide screening log documentation for staff; facility failed to cover trash cans with lids
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4