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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600459
Report Date: 05/09/2022
Date Signed: 05/09/2022 06:29:11 PM

Document Has Been Signed on 05/09/2022 06:29 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:NEW LIFE RESIDENCEFACILITY NUMBER:
415600459
ADMINISTRATOR:CAMACLANG, TINAFACILITY TYPE:
740
ADDRESS:976 NORTONTELEPHONE:
(650) 579-1131
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 4DATE:
05/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Deborah Jennings and Genny FloresTIME COMPLETED:
06:45 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms--all with half bathrooms--1 staff room, a common bathroom, shower room, kitchen and living/dining room. There is an enclosed patio and backyard. Washer and dryer are located in 2 car garage. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, and a comfortable temperature is maintained. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete, and staff have current first-aid training. A Disaster and Mass Casualty Plan is posted. There are 4 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Currently, there is no certified RCFE administrator associated with facility. See Technical Assistance (LIC9102TA) for details.
>>>>Copy of RCFE Administrator Certificate to be submitted to CCLD when obtained.

The following updated forms/information are requested to be submitted to CCLD by 5/16/22:

• Current liability insurance
• LIC 500 Personnel Report
• LIC 308 Designation of Facility Responsibility
• LIC 610E Emergency Disaster Plan

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page.

See Technical Advisory Notes for additional information.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2022
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 05/09/2022 06:29 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/09/2022 at 05:28 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: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2(a)(4)
In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of facility log and interview with co-administrator, the licensee did not comply with the section cited above, as daily temperature and COVID symptom checks are not recorded for staff and clients since March 2022, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/16/2022
Plan of Correction
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Staff shall limmediately resume logging COVID symptom checks and temperatures of staff and clients. Plan of correction to be sent to CCLD BY DUE DATE.
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 Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/09/2022 06:29 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/09/2022 at 05:48 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: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608)a)(5)(A)
POSTURAL SUPPORTS
A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of 2 half bed rails on bed in room #4, occupied by client #3, the licensee did not comply with the section cited above. There are 2 half bed rails installed on both sides of bed at the foot of the bed, in addition to 2 half rails installed at the head of the bed on both sides. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/09/2022
Plan of Correction
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Two half bed rails at the foot of the bed in room #4 were removed in LPA's presence.
Deficiency corrected and cleared during visit.
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 Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2022


LIC809 (FAS) - (06/04)
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