415600358-11-19-2024-14-AS-MHAN-DB6RSE-20241119121637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600358
Report Date: 11/19/2024
Date Signed: 11/19/2024 06:19:43 PM

Document Has Been Signed on 11/19/2024 06:19 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:	AHAU BOARDING CARE HOME		FACILITY NUMBER:	415600358
ADMINISTRATOR/ DIRECTOR:	LATU, TEMALETI T.		FACILITY TYPE:	740
ADDRESS:	901 KAINS AVENUE		TELEPHONE:	(650) 866-9172
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY: 5	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	11/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Administrator, Temaleti Latu		TIME VISIT/ INSPECTION COMPLETED:	12:30 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 November 19, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with the administrator and explained the purpose of today's visit. LPA toured the facility inside and out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility has 3 resident rooms (2 shared and 1 private). Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care. Hot water temperature in the kitchen and bathroom were measured at 108-111 degrees Fahrenheit. Fire extinguishers were checked. 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. During today's visit, LPA observed the administrator was the only staff at the facility and when she was providing a shower for resident #1 (R1), the other 3 residents were in the dining room unattended and resident #2 (R2) called out several times for assistance before he/she was attended to.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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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Document Has Been Signed on 11/19/2024 06:19 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: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a storage unit in the back yard that is being used as a living space for one of the caregivers which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to address the storage unit in the backyard that is being used as a living space and the plan shall indicate the steps that the administrator will take if the storage unit is deemed to be inhabitable by the Fire Marshal. The administrator will provide a copy of the plan to CCL 11/20/2024.

Section Cited

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator was not able to provide any documents to proof that emergency drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure emergency drills are conducted accordingly and will provide a copy of the plan to CCL by 11/20/2024. The plan shall include staff education and a schedule of the emergency drills.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the inspection, the administrator was the only staff on-site and she was giving a shower to R1, the other 3 residents were left unattended in the dining room and R2 called out serveral times for assistance before he/she was attended to which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan in writing to ensure there is an adequate number of direct care staff to support each resident's needs and they are being supervised at all times. The administrator will submit a copy of the LIC500 and a copy of the plan to CCL by 11/20/2024.

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.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/19/2024 06:19 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: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above the administrator stated that the liability insurance has not been renewed which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the current Liability Insurance to CCL by 11/26/2024.

Section Cited

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator was not able to provide proof that the training was completed for Staff #1(S1) which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the required training records for S1 to CCL by 11/26/2024.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/19/2024 06:19 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: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R3 has a diagnosis of dementia and the LIC 602 was not completed annually which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/26/2024
	Plan of Correction
1 2 3 4	The administrator will provide a copy of updated LIC602 for R3 and provide a copy to CCL by 11/26/2024.

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.

April Cowan	TELEPHONE: (650) 266-8889
Murial Han	TELEPHONE: (619) 209-9761
	DATE: 11/19/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

Page: 5 of 6

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: AHAU BOARDING CARE HOME	FACILITY NUMBER: 415600358
	VISIT DATE: 11/19/2024

NARRATIVE

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During the tour of the facility, LPA observed a storage unit in the back yard was converted into a living space and according to the administrator, this is a living space for the caregiver and the facility did not have any documents to proof that this is an approved habitable space.

Civil penalty in the amount of $250 is being assessed today for repeat violation.

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 an additional civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/19/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024

LIC809 (FAS) - (06/04)

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