415600616-11-17-2023-14-AS-JCAA-CXP3DX-20231117171016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 11/17/2023
Date Signed: 11/17/2023 05:10:20 PM

Document Has Been Signed on 11/17/2023 05:10 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:	DIAZ, YOLANDA		FACILITY TYPE:	740
ADDRESS:	924 CEDAR STREET		TELEPHONE:	(650) 728-3132
CITY:	MONTARA	STATE: CA	ZIP CODE:	94037
CAPACITY:	17	CENSUS: 15	DATE:	11/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Myralee Casamina, Assistant Administrator and Rosa Diaz, Licensee/Administrator		TIME COMPLETED:	05:15 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	On November 17, 2023, Licensing Program Analyst(LPA) John Calandra, and Licensing Program Manager(LPM)Jackie Jin arrived at the licensed facility to conduct an Annual 1-year required inspection. LPA Calandra and LPM Jin met with Assistant Administrator Myralee Casamina and Administrator, Rosa Diaz joined later. The visit commenced with a tour of the facility in which resident bedrooms, kitchen, living room, dining room, office, medication room, and basement. Adequate furniture and sufficient lighting were observed in resident bedrooms. Two days of perishables and 7 days of non-perishables were observed. All bathrooms were equipped with anti-skid flooring and grab bars. Water temperature in all bathrooms were measured between 105 and 114.6 degrees Fahrenheit. All fire extinguishers were last checked in March of 2022 and fire and carbon monoxide detectors were observed to be in working order. All fire extinguishers were observed to be charged. Sufficient night lights were observed throughout the facility. Sharps are stored appropriately and inaccessible to residents in the kitchen with a lock on the door and staff locks the door when he/she leaves the kitchen. The facility, backyard, and front yard were observed to be free of hazards/obstructions and no accessible bodies of water were observed. There are 15 residents, and 5 staff members present during the inspection. During an inspection of the kitchen and basement storage room, expired food was observed. In the presence of the LPA and LPM the Assistant Administrator Myralee Casamina removed the expired foods and disposed of them properly. A technical violation was provided. Furthermore, during the tour LPA and LPM observed the facility's medication room door to be open and accessible to persons in care. In the presence of the LPA and LPM, Assistant Administrator, Myralee Casamina locked the door. LPA and LPM advised that facility ensure medications room always being locked and train staff.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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: 11/17/2023

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LPA Calandra and LPM Jin also observed Lysol wipes and spray to be unlocked and accessible to persons in care. Assistant Administrator removed them in the presence of the LPA and LPM.

LPA Calandra and LPM Jin reviewed seven client records which were complete with signed Admissions Agreements, Physician's reports, Needs and Services/Care plans, signed consent forms, etc.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility.

LPA Calandra and LPM Jin requested for a copy of the facility's limited liability insurance to be sent to the department by November 24, 2023.

LPA Calandra and LPM Jin will return to facility to complete the Annual Inspection at a later date.

No deficiencies were cited during today's visit. A copy of the Report and Technical Violation was reviewed with Assistant Administrator, Myralee Casamina and Administrator/Licensee Rosa Diaz and left at the facility.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

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