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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600444
Report Date: 03/28/2022
Date Signed: 03/28/2022 11:18:12 AM


Document Has Been Signed on 03/28/2022 11:18 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:CHAD CORNER ASSISTED LIVINGFACILITY NUMBER:
415600444
ADMINISTRATOR:SANTOTOMAS, CARMELITA P.FACILITY TYPE:
740
ADDRESS:2901 SHANNON DR.TELEPHONE:
(650) 588-5391
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 4DATE:
03/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Licensee/Administrator, Carmelita SantotomasTIME COMPLETED:
11:30 AM
NARRATIVE
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On March 28, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed COVID signage posted at the front door, but LPA discussed the need to add more reminder signage (masking, COVID symptoms, social distancing, cough etiquette) on the front door and throughout the facility. LPA was greeted by the Licensee, Carmelita Santotomas and explained the purpose of the visit. LPA was not screened at entry point and the Licensee was unable to provide screening log documentation for visitors, residents, and staff. This is a two story facility; 2 bedrooms, 1 full and 1 half bathroom on the first floor and 4 bedrooms and two full bathrooms on the second floor.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not observed: entry procedures and screening log documentation for staff, visitors, and residents. LPA observed the bathrooms and advised Licensee to ensure all bathrooms have the following; hand-washing signs, liquid soap, covered trash bin, and paper towels. In addition, LPA Charitra advised Licensee to remove all hand-towels and bar soaps and just keep paper-towels and liquid soap. LPA observed two shared resident bedrooms on the first floor with beds 6ft apart.

LPA toured the kitchen and advised Licensee to switch out hand-towels for paper-towels and disinfectant wipes. LPA Charitra observed the sharps drawer to be unlocked and accessible to residents during the visit. Licensee immediately locked the knives in LPA's presence. LPA observed 2 day perishable and 7 day non-perishable . In addition, LPA observed the emergency food supply present. Medications and toxins are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained, lighting is sufficient for comfort. First aid kit was observed to be completed. (CONT. to 809C)
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CHAD CORNER ASSISTED LIVING
FACILITY NUMBER: 415600444
VISIT DATE: 03/28/2022
NARRATIVE
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LPA Charitra toured the second floor of the facility, According to the Licensee, it was indicated that the second floor is ONLY for staff members. There are a total of 4 bedrooms and 2 full bathrooms on the second floor. 1 out of the 4 bedrooms are vacant at this time.

The following updated forms are requested to be submitted to CCLD by 4/4/22:
• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC 400 Resident Cash Resources

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.

This report is reviewed and discussed with the Licensee; a copy is provided.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/28/2022 11:18 AM - 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CHAD CORNER ASSISTED LIVING
FACILITY NUMBER: 415600444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee failed to lock up the knives immediately after using which makes it accessible to residents in care. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2022
Plan of Correction
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Licensee immediately locked up the knives in LPA's prescense. Licensee to submit acknowledgement of Title 22, Regulation 87705, Care of Persons with Dementia. Licensee to conduct staff training and submit proof of training log to LPA by 4/1/22
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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 03/28/2022 11:18 AM - 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: CHAD CORNER ASSISTED LIVING
FACILITY NUMBER: 415600444

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
(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:
Deficient Practice Statement
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Based on observations and record reviews,The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2022
Plan of Correction
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The Licensee and/or designee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening process for visitors, residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done. The Licensee will in-service staff members on this procedure and the Administrator will provide a copy of the sign-in sheet and the required logs to the Department by 4/4/2022.
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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4