<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600616
Report Date: 02/01/2023
Date Signed: 02/03/2023 01:42:17 PM


Document Has Been Signed on 02/03/2023 01:42 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 CEDAR LANE CARE HOME, INC.FACILITY NUMBER:
415600616
ADMINISTRATOR:DIAZ, YOLANDAFACILITY TYPE:
740
ADDRESS:924 CEDAR STREETTELEPHONE:
(650) 728-3132
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:17CENSUS: 16DATE:
02/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrative Manager, Gerogina AguirreTIME COMPLETED:
12:10 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 2/1/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by administrative manager, Gerogina Aguirre. LPA explained the purpose of the visit. Administrative manager informed the administrator of LPA's visit by phone.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate; COVID-19 signs are posted through-out the facility; bathrooms are equipped with soap and paper towels; hand washing instruction is posted by the hand washing stations; trash cans are observed to have foot operated lids. The facility has 2-bed rooms and private rooms. The beds in the shared rooms are observed to be 6" apart.

Medications and chemicals are observed to be locked in a storage room with a digital lock. 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. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kits are inspected and complete. There are 16 residents, and 5 staff members present during the inspection.

During today's visit, LPA reviewed the daily COVID-19 screening logs for residents and facility from Novemer 26th, 2022 to February 1st, 2023 and observed facility is conducting daily screening for residents. However, it is not being consistently completed for facility staff as there were many omissions on the logs to show that facility staff was not screened on a daily basis.

Based on observation, and record review, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrative manager. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 02/03/2023 01:42 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 CEDAR LANE CARE HOME, INC.
FACILITY NUMBER: 415600616

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above as the daily COVID-19 logs from Nov 26th, 2022 to February 1, 2023 observed with many omissions showing that facility staff were not screened on a daily basis which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/08/2023
Plan of Correction
1
2
3
4
The administrator will provide in-service to facility staff on the importance of daily screening and documenting the results from the screening. The administrator will provide a copy of the in-service sign-in record to CCL by 2/8/2023. In addition, the administrator will provide a copy of the completed daily facility COVID-19 screening log for staff from 2/1/2023 to 2/8/2023 to CCL by 2/8/2023.
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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/01/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2