415600616-12-19-2024-14-AS-DTOA-DC4RXD-20241219122434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:24:48 PM

Document Has Been Signed on 12/19/2024 12:24 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 CEDAR LANE CARE HOME, INC.		FACILITY NUMBER:	415600616
ADMINISTRATOR/ DIRECTOR:	DIAZ, YOLANDA		FACILITY TYPE:	740
ADDRESS:	924 CEDAR STREET		TELEPHONE:	(650) 728-3132
CITY:	MONTARA	STATE: CA	ZIP CODE:	94037
CAPACITY: 17	TOTAL ENROLLED CHILDREN: 0	CENSUS: 17	DATE:	12/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Myra Casamina, Assistant Administrator, Rosa Diaz & Yolanda Diaz, Licensees		TIME VISIT/ INSPECTION COMPLETED:	12:30 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	On 12/19/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator Assistant, Myra Casamina. Licensees Rosa & Yolanda Diaz were notified and arrived later in the visit. The facility currently provides care for 17 residents, none of which are currently receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the hallways, kitchen and common spaces were found to be charged. Facility is equipped with interconnected smoke and carbon monoxide detectors all of which were found to be in working order. In addition, fire safety systems monitored and serviced by outside agencies with last inspection in 2024. Emergency Disaster Plan has been updated with appropriate guidelines and evacuations sites. There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen and additional storage room, sufficient for residents in care. Food supply is replenished multiple times per week and stored in proper conditions. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked in designated storage and laundry room, which was secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Residents that were out in the community were observed interacting with staff, fellow residents in the common areas, participating in activities and family visits. The facility encourages regular family visits and utilizes a large outdoor patio, garden, and common areas. LPA observed residents to have a strong relationship with staff, with LPA finding the level of care and engagement to be exceedingly positive. Continued onto LIC809-C

Andrea Medlin	TELEPHONE: (650) 266-8811
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

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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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 CEDAR LANE CARE HOME, INC.	FACILITY NUMBER: 415600616
	VISIT DATE: 12/19/2024

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LPA conducted a sample file review for residents and found that the facility is in the process of updating medical assessments and reappraisal care plans for residents with a diagnosis of dementia. LPA found that the facility has contacted resident physicians and is in process of completing medical appointments. In addition, resident reappraisals have been completed for residents with signatures pending. LPA determined that the facility has taken appropriate steps and actively working on completing resident records. License agrees to ensure medical assessment and reappraisals for all residents are current. Technical Assistance issued. Upon a sample file review for staff, LPA found that annual training requirements and 1st aid & cpr certification were completed. Lastly, upon a spot check of medication and medication records, LPA found all items including prescription and fill dates to be documented.

LPA requested the following documents be sent to CCL by COB 1/9/2025:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

No deficiencies cited during today's visit.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024

LIC809 (FAS) - (06/04)

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