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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600602
Report Date: 02/06/2024
Date Signed: 02/06/2024 01:49:06 PM


Document Has Been Signed on 02/06/2024 01:49 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:ROYAL ILIMAFACILITY NUMBER:
415600602
ADMINISTRATOR:GANIO, PUREZA A.FACILITY TYPE:
740
ADDRESS:1565 ROYAL AVE.TELEPHONE:
(650) 348-3895
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 6DATE:
02/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ely Ganir and Antolin UcolTIME COMPLETED:
02:00 PM
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LPA Audrey Jeung toured facility and grounds of this facility that serves elderly developmentally disabled persons. There are 3 shared client bedrooms, activity room, 2 full bathrooms, kitchen and living/dining room on ground floor. There is a bathroom and 2 staff rooms on 2nd floor; one room has 4 beds and the other has 2 beds. The washer and dryer are located in attached 1-car garage and extra supplies are stored in storage shed in backyard. There are no accessible bodies of water or fire safety hazards observed. Toxins, medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Pureza Ganio and Antolin Ucol are certified RCFE administrators that oversee facility operations. Night staff is awake.

As per legislation, effective 1/1/2015, the following information is posted: 1) PUB474, pertaining to resident councils, per AB1572; 2) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 3) CCLD Hotline information, per SB895.

The following licensing forms are requested to be completed and submitted to CCLD BY 2/20/24:
- Administrative Organization (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Affidavit regarding Client Cash REsources (LIC400)
- Emergency Disaster Plan (LIC610-E signed and dated on page 9)
- Proof of control of property (current signed lease)

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Also, see Advisory Notes issued--5 pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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 02/06/2024 01:49 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: ROYAL ILIMA
FACILITY NUMBER: 415600602

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff training records review, the licensee did not comply with the section cited above, as there is no evidence that ALL staff received required 4 hours of annual training on postural supports, hospice care and restricted health conditions. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/20/2024
Plan of Correction
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Documentation that all staff received required 4 hours of training on postural supports, hospice care and restricted health conditions will 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
LIC809 (FAS) - (06/04)
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