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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600358
Report Date: 11/01/2023
Date Signed: 11/01/2023 01:40:03 PM

Document Has Been Signed on 11/01/2023 01:40 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: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:
11/01/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Temaleti TIME COMPLETED:
01:40 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 1, 2023 Licensing Program Analyst (LPA) Murial Han conducted a 10-day complaint visit in reference to complaint # 14- AS- 20231027125651, and during the visit, LPA make the following observations.

At 10:30AM, LPA arrived at the facility, and rang the door bell twice but no one answered. After 10 minutes of waiting, resident # 1( R1) who was watching TV in the living room noted from the window that LPA was waiting outside and opened the door for LPA. As R1 was opening the door, a dog ran out to the street from the facility.

LPA proceed to enter the facility and did not observe any facility staff was present.

LPA interviewed R1 in the living room and R1 stated that he/she did not know where the staff was. LPA observed resident #2 (R2) who was eating breakfast in the dining room and also reported that he/she did not know where the staff was. LPA waited by the front door / living area and yelled for assistance for about 8 minutes and no one responded. LPA proceed to called and spoke to the administrator via cell phone and after a few minutes, the administrator came out and stated that she was taking a shower and she was the only staff at the facility.

During the tour of the facility, LPA observed a knife was placed on the counter next to the stove, dirty dishes were in the sink cover with dirty water, big pile of soiled clothes on the floor in the laundry room, big soiled towel on the living room floor, in front of the fire place, fruits were placed next to big piles of paper and clothes in the kitchen counter, several piles of clothes in front of the staff room area, and a thick layer of white dust on top of the unused paper towel dispenser in the bathroom.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
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: AHAU BOARDING CARE HOME
FACILITY NUMBER: 415600358
VISIT DATE: 11/01/2023
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
26
27
28
29
30
31
32
Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. An immediate civil penalty was assessed for Absence of supervision. Failure to correct the deficiency may result in additional civil penalty.

Appeal Rights provided.

This report was reviewed and discussed with administrator at the end of the inspection.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/01/2023 01:40 PM - It Cannot Be Edited


Created By: Murial Han On 11/01/2023 at 12:25 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
CCR
1569.0822(c)(3)

1
2
3
4
5
6
7
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:..
1
2
3
4
5
6
7
The administrator/licensee will develop a plan to ensure residents are being supervised at all times. Administrator/licensee will provide a copy of the plan to CCL by 11/2/2023.
8
9
10
11
12
13
14
(3) Absence of supervision as required by statute or regulation. This requirement is not met as evidenced by there was absence of supervision when LPA arrived at the facility as the only staff (administrator) was taking a shower which poses an immediate health risks for residents in care.
8
9
10
11
12
13
14
Immediate Civil Penalty is being assessed today (11/1/2023) for absence of supervision.
Type A
11/02/2023
Section Cited
CCR87309(a)

1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
The administrator/licensee will develop a plan to ensure all items that could pose a danger is inaccessible to residents at all times. The administrator/licensee will submit a copy of this plan to CCL by 11/2/2023.
8
9
10
11
12
13
14
This requirement is not met as evidence by LPA observed a knife on the counter next to the stove which poses an immediate health risks to residents in care.
8
9
10
11
12
13
14
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/01/2023 01:40 PM - It Cannot Be Edited


Created By: Murial Han On 11/01/2023 at 12:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation..(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by LPA observed dirty dishes in the sink, big pile of soiled
1
2
3
4
5
6
7
The administrator/licensee will provide proof that facility is clean, safe, sanitary and submit a copy of the proof (photos) to CCL by 11/2/2023. Administrator/Licensee will submit a plan
8
9
10
11
12
13
14
clothes on the laundry room floor, fruits were stored on the counter with piles of paper, the unused towel paper dispenser in the bathroom was covered a white layer of dust etc. which poses an immediate health risk to residents in care.
8
9
10
11
12
13
14
on how the facility will maintain and sustain a clean, safe, and sanitary environment for resident. Administrator/Licensee will submit a copy of the plan to CCL by 11/2/2023.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2023


LIC809 (FAS) - (06/04)
Page: 4 of 4