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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600425
Report Date: 08/05/2025
Date Signed: 08/05/2025 09:23:09 PM

Document Has Been Signed on 08/05/2025 09:23 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:C & C CAREHOMEFACILITY NUMBER:
415600425
ADMINISTRATOR/
DIRECTOR:		ETHEL AZCUETA-GUMBANFACILITY TYPE:
740
ADDRESS:2700 OAKMONT DRIVETELEPHONE:
(650) 583-3496
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 6DATE:
08/05/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Caregiver, Corazon RodriguezTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
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On August 5, 2025 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon arrival, LPA was greeted by caregiver, Corazon Rodriguez and LPA explained the purpose of today's visit. The Administrator, Ethel Gumban arrival shortly thereafter and assisted with the inspection.

LPAs 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 full baths, one a half bath, and 1 staff room. LPA observed 2 shared resident rooms. LPA observed the other 2 resident rooms to be private.

LPA toured the living and dining room and observed it to be clean and clear from any tripping hazards. A comfortable temperate is maintained. Lighting was sufficient for comfort. Extra linen was observed to be present. LPA toured the kitchen and observed medication, and chemicals to be locked and inaccessible to residents in care. LPA observed sharps in the kitchen drawer to be unlocked and accessible to residents in care. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable.

LPA toured the garage where the washer and dryer were observed to be in good working condition.

Hot water temperature in the kitchen and bathroom were measured at 106- 112 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 3/20/2025. Disaster drills were reviewed.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/05/2025
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 12
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above at 9:47am, during the facility tour, LPA observed the tiles around the kitchen sink were broken and the wooden fence in the backyard moves with chipped paint and sharp edges.
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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The administrator/licensee will submit a plan of correction indicating the repair of the broken tiles around the kitchen sink and the wooden fence and the plan shall indicate the repairs shall be completed by 8/13/2025. The administrator/licensee will submit a copy of the plan of correction to CCL by 8/6/2025.
Type A
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above at 9:47am, during the facility tour, LPA observed the kitchen floor edges, the bathroom floor and the living room floor appeared with black dust, black and brown particles, the rice cooker has brown spots, the kitchen vent consists of black sticky particles and the top of the refrigerator has a layer of black and grey particle. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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4
The administrator/licensee will submit a plan of correction indicating the process to ensure the identified areas are clean and to ensure the overall cleanliness of the facility. The identified areas shall be cleaned by 8/13/2025. The administrator/licensee will submit a copy of the plan of correction to CCL by 8/6/2025.
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as during the facility tour, LPA observed the knifes in the kitchen drawer was unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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The administrator/licensee will replace the key for the drawer and in-service staff to lock the drawer at all times. The administrator/ licensee will provide a copy of the plan of correction to CCL by 8/6/2025.
Type A
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above S1 was hired in May 2025 and the facility was not able to provide training records to proof that the on-the - job training was completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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The administrator will provide a plan of correction indicating the date that S1 will complete all the required training and the date of completion shall be no later than 8/13/2025. The administrator/licensee will provide a copy of the plan of correction by 8/6/2025.
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above S1 was hired in May 2025 and the facility was not able to provide training records to proof that S1 has received sufficient training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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The administrator will provide a plan of correction indicating the date that S1 will complete all the required training and the date of completion shall be no later than 8/13/2025. The administrator/licensee will provide a copy of the plan of correction by 8/6/2025.

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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 5 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
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 The facility was not able to provide documents to proof that the annual training was completed for S2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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2
3
4
The administrator will provide a plan of correction indicating the date that S2 will complete all the required training and the date of completion shall be no later than 8/13/2025. The administrator/licensee will provide a copy of the plan of correction by 8/6/2025.
Type A
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above R6 was admitted on 8/4/2025 and the pre-admission appraisal was blank which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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2
3
4
The administrator/licensee will complete the pre-admission appraisal for R6 and will provide a copy to CCL by 8/6/2025.
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 6 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87458(c)(1)(A)
Medical Assessment
(c) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the licensed medical professional's diagnosis or diagnoses and results of an examination for all of the following: (A) Communicable tuberculosis.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above R2's Communicable Tuberculosis status was blank on the medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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2
3
4
The administrator will provide a plan of correction on how to obtain the TB status and submit a plan to CCL by 8/6/2025 and the plan shall indicate the date of completion no later than 8/13/2025.
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

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 R2 has bed rails without a written physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
1
2
3
4
The administrator will provide a plan of correction on how to obtain the written physician's order for the bed rail and submit a plan to CCL by 8/6/2025 and the plan shall indicate the date of completion no later than 8/13/2025.
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 7 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

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 R1 has bed rails and pads on both sides of the bed that extend the entire bed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
1
2
3
4
The administrator/licensee will provide a plan of correction indicating a reassessment of the bed rails and the pads and the plan shall indicate the facility's action after the reassessment. if the facility decided to keep the bed rails and the pad, the facility shall submit an exception no later than 8/13/2025.
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 8 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:11 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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 facility was not able to provide documents to proof that the reappraisals are completed for R1, R3 and R5. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
1
2
3
4
The administrator/licensee will submit a copy of the reappraisals for R1, R3 and R5 to CCL by 8/13/2025.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

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/ licensee was not able to provide proof that the plan was reviewed annually which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
1
2
3
4
The administrator/licensee will submit a copy of the annual review of the emergency/disaster plan to CCL by 8/13/2025.
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
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
Page: 9 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.605
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
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator/licensee was not able to provide a copy of the current Liability Insurance. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2025
Plan of Correction
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The administrator/licensee will provide a copy of the current liability insurance to CCL by 8/13/2025.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


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: C & C CAREHOME
FACILITY NUMBER: 415600425
VISIT DATE: 08/05/2025
NARRATIVE
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During the tour of the facility at 9:47AM, LPA observed the kitchen floor edges, the bathroom floor and the living room floor appeared with black dust, and brown particles, the rice cooker has brown spots, the kitchen vent consists of black sticky particles and the top of the refrigerator has a layer of black and grey particle.

In addition, LPA observed the tiles around the kitchen sink were broken and the wooden fence in the backyard moves with chipped paint and sharp edges.

During the review of personnel file review, LPA observed, Staff #1 (S1) was hired in May 2025 and the facility was not able to provide training records to proof that the on-the-job training was completed accordingly and the facility was not able to provide training records to proof that S1 has received sufficient training. LPA observed the facility was not able to provide documents to proof that the annual training was completed for staff #2 (S2).

During the review of resident files, LPA observed resident #6 (R6) was admitted on 8/4/2025 and the pre-admission appraisal was blank, and resident #2 (R2)'s Communicable Tuberculosis status was blank on the medical assessment

In addition, R2 has bed rails without a written order by the physician and R1 has bed rails and pads on both sides of the bed that extend the entire bed.

Based on S1’s Personnel Record (LIC501), S1 was hired on May 21, 2025, but the Dementia Training records included S1’s signatures for attending three in-services in February 2025. The administrator/licensee was not able to explain the signatures.

The above findings poses/posed an immediate health, safety or personal rights risk to persons in care.

During the review of the facility's records, the administrator/licensee was not able to provide a copy of the current Liability Insurance, the administrator/licensee was not able to provide proof that the emergency/disaster plan was reviewed annually and the administrator/licensee was not able to provide documents to proof that the reappraisals for resident #1( R1), resident #3 (R3) and resident #5 (R5) were completed.

The above findings poses/posed a potential health, safety or personal rights risk to persons in care.

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 civil penalties.



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

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC809 (FAS) - (06/04)
Page: 11 of 12
Document Has Been Signed on 08/05/2025 09:23 PM - It Cannot Be Edited


Created By: Murial Han On 08/05/2025 at 12:44 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: C & C CAREHOME
FACILITY NUMBER: 415600425

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87207(a)
87207 False Claims

No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement is not met as evidenced by: Based on S1’s Personnel Record (LIC501), S1 was hired on May 21, 2025, but the Dementia Training records included S1’s signatures for attending three in-services in February 2025. The administrator/licensee was not able to explain the signatures.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Based on S1’s Personnel Record (LIC501), S1 was hired on May 21, 2025, but the Dementia Training records included S1’s signatures for attending three in-services in February 2025. The administrator/licensee was not able to explain the signatures which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/06/2025
Plan of Correction
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The administrator/licensee will review the regulation and provide a signed and dated statement of acknowledgement after the review and provide in-services to staff. The administrator/licensee will provide a copy of the in-service record and the statement of acknowledgement to CCL by 8/6/2025.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/05/2025


LIC809 (FAS) - (06/04)
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