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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600358
Report Date: 11/16/2023
Date Signed: 11/16/2023 10:44:24 AM

Document Has Been Signed on 11/16/2023 10:44 AM - 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:AHAU BOARDING CARE HOMEFACILITY NUMBER:
415600358
ADMINISTRATOR:LATU, TEMALETI T.FACILITY TYPE:
740
ADDRESS:901 KAINS AVENUETELEPHONE:
(650) 866-9172
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 5CENSUS: 5DATE:
11/16/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Temaleti LatuTIME COMPLETED:
11:00 AM
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On November 16, 2023, Licensing Program Analyst (LPA) conducted an unannounced Plan of Correction (POC) visit to follow up on deficiencies cited on November 1, 2023 during a complaint visit.

Upon arrival, administrator, LPA met with Temaleti Latu and caregiver, Emily Latu and explained the purpose of today's visit.

Administrator provided a tour of the facility and LPA observed medicine cabinets were locked and inaccessible to residents in care, sharps and chemicals were locked and inaccessible to residents in care, new dining room furniture was purchased, living room appeared to be cleaned, no soiled clothes on the laundry room floor and no dirty dishes in the sink.

The following deficiencies are cleared:

Section: 87465 Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons...

Section:ยง1569.49 Civil penalties; regulations setting forth appeal procedures for deficiencies..(c) The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for any of the following serious violations:..
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2023
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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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: AHAU BOARDING CARE HOME
FACILITY NUMBER: 415600358
VISIT DATE: 11/16/2023
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87309 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.

87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times.


Report is reviewed with administrator; POC letter is generated and provided on this day.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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