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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600459
Report Date: 01/30/2024
Date Signed: 01/30/2024 05:39:51 PM


Document Has Been Signed on 01/30/2024 05:39 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:NEW LIFE RESIDENCEFACILITY NUMBER:
415600459
ADMINISTRATOR:CAMACLANG, TINAFACILITY TYPE:
740
ADDRESS:976 NORTONTELEPHONE:
(650) 579-1131
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
01/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Deborah Jennings and Genny FloresTIME COMPLETED:
05:30 PM
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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 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 adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. 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 6 residents present and 2 staff. LPA interviewed 2 residents. One resident is receiving 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. Tina Camaclang and Genny Flores are certified RCFE administrators (x 2/24 and 1/25) that oversee facility operations.

The following information/forms are requested to be submitted to CCLD BY 2/13/24:

- Designation of Facility Responsibility (LIC308)
- Personnel Report (LIC500)
- Emergency Disaster Plan (LIC610E)
- Facility Floor Plan (LIC999 including all bathrooms)
- Proof of current liability insurance
- Annual licensing fees due $1237 or proof of payment

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Technical Violations are issued--see 7 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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 01/30/2024 05:39 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: NEW LIFE RESIDENCE
FACILITY NUMBER: 415600459

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of clients' medications, the licensee did not comply with the section cited above, as staff prepare clients' medications 7 days in advance, which poses a potential health, safety or personal rights risk to persons in care. Plastic containers containing daily medications for 7 days are observed.
POC Due Date: 02/13/2024
Plan of Correction
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Effective immediately, medication shall not be prepared more than ONE day in advance. Plan/proof of correction to be submitted 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
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