415600459-1-14-2025-14-AS-AJEG-DCX4FH-20250114180358

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600459
Report Date: 01/14/2025
Date Signed: 01/14/2025 06:04:10 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 01/14/2025 06:04 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:	NEW LIFE RESIDENCE		FACILITY NUMBER:	415600459
ADMINISTRATOR/ DIRECTOR:	CAMACLANG, TINA		FACILITY TYPE:	740
ADDRESS:	976 NORTON		TELEPHONE:	(650) 579-1131
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/14/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:00 PM
MET WITH:	Deborah Jennings and		TIME VISIT/ INSPECTION COMPLETED:	06:15 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	LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 6 client bedrooms--all with half bathrooms and exit doors--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. PPE supply is inspected. Food supplies are maintained. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and hot water temperature tested at 118 degrees. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present and 2 staff. Two residents receive hospice services. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Genny Flores is a RCFE administrator (x 1/25) that has submitted education certificates in October 2024 for renewal of administrator certificate. The following information/forms are requested to be submitted to CCLD BY 1/21/25: - Facility Floor Plan (LIC999 including all bathrooms) - Proof of current liability insurance Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.

April Cowan	TELEPHONE: (650) 266-8889
Audrey Jeung	TELEPHONE: (650) 266-8891
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

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 01/14/2025 06:04 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: NEW LIFE RESIDENCE	FACILITY NUMBER: 415600459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

INCIDENTAL MEDICAL CARE Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement was not met, as 2 bottles of Vit D3 stored in common
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	Vitamin D3, acetaminophen and Vit C relocated to inaccessible storage area in LPA's presence. Deficiency corrected and cleared

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
Audrey Jeung	TELEPHONE: (650) 266-8891
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/14/2025 06:04 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: NEW LIFE RESIDENCE	FACILITY NUMBER: 415600459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

PERSONAL RIGHTS Residents in all RCFEs shall have the personal right to have access to individual storage space for private use. This requirement is not met, as personal items belonging to staff are stored in closet in client room #3. Licensee failed
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Personal belongings of staff will be removed from clients' rooms and proof of correction to be sent to CCLD BY DUE DATE

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
Audrey Jeung	TELEPHONE: (650) 266-8891
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/14/2025 06:04 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: NEW LIFE RESIDENCE	FACILITY NUMBER: 415600459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

MAINTENANCE AND OPERATION 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 discarded
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Ceiling was temporarily covered in LPA's presence. Discarded items will be removed from premises and proof of correction to be sent to CCLD BY DUE DATE

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
Audrey Jeung	TELEPHONE: (650) 266-8891
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 01/14/2025 06:04 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: NEW LIFE RESIDENCE	FACILITY NUMBER: 415600459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HEALTH AND SAFETY CODE The failure of an applicant for licensure or a licensee to pay all applicable and accrued fees and civil penalties shall constitute grounds for denial or forfeiture of a license. This requirement is not met, as licensee has failed to pay annual licensing renewal fees
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Annual licensing fees and late charges totalling $1979 will be paid BY DUE DUE DATE. Proof of payment/correction to be sent to CCLD BY DUE DATE.

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
Audrey Jeung	TELEPHONE: (650) 266-8891
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

Page: 5 of 6

Document Has Been Signed on 01/14/2025 06:04 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: NEW LIFE RESIDENCE	FACILITY NUMBER: 415600459
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

HEALTH AND SAFETY CODE Each employee who received training and passed the exam required in paragraph (5) of subdivision (a)... who continues to assist with the self-administration of medicines, shall also complete 4 hours of in-service training on medication-related issues in each
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/21/2025
	Plan of Correction
1 2 3 4	Staff who handle clients' medications will receive at least 4 hours of annual medication training. Proof/plan of correction to be sent to CCLD BY DUE DATE.

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
Audrey Jeung	TELEPHONE: (650) 266-8891
	DATE: 01/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2025

LIC809 (FAS) - (06/04)

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