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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600683
Report Date: 11/19/2023
Date Signed: 11/21/2023 03:17:13 PM


Document Has Been Signed on 11/21/2023 03:17 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:ACCESS CARE CENTERFACILITY NUMBER:
415600683
ADMINISTRATOR:HIPOLITO, CRISTINA/MARLYNFACILITY TYPE:
740
ADDRESS:2511 CATALPA WAYTELEPHONE:
(650) 952-5228
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
11/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Khin Htay and Alvin GalangTIME COMPLETED:
01:00 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 11/19/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregivers, Khin Htay and Alvin Galang, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator to inform him/her that CCL was present at this time for an annual visit. The facility designated Administrator was unable to be present at today's annual visit but gave consent for the caregivers to sign all documents at this time.
Current census was 5 residents. There was one resident under the care of hospice at this time according to statements made by the facility caregivers. This facility does have an approved hospice waiver to be able to accept and retain up to (3) hospice residents at any given time.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the kitchen cabinets and drawers, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility staff at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was observed to be locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023
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: ACCESS CARE CENTER
FACILITY NUMBER: 415600683
VISIT DATE: 11/19/2023
NARRATIVE
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A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient
and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were reviewed to make sure that they were present and in good repair at this time.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located in the garage, was observed to be unlocked but did not house any detergents, soaps, or bleach at this time. It was learned that all cleaning and laundry supplies were separately locked and made inaccessible to the residents at all times.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. Additional food storage units were observed to be present and in good repair at this time.
First aid kit, located in kitchen area, was observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to have been annually inspected on 09/07/2023 by the local fire extinguisher company, So City Fire Protection, and in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
A review of (5) resident files was conducted and noted on the LIC 858.
A review of (4) resident staff files was conducted and noted on the LIC 859.
The following forms and documents were requested to be updated and submitted into CCL in order to update this facility file:
  • LIC 308
  • LIC 400
  • LIC 500
  • LIC 610


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Appeal Rights were printed and a copy was given to the facility representative at this time. Exit Interview
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 11/21/2023 03:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ACCESS CARE CENTER
FACILITY NUMBER: 415600683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the resident restroom faucets were delivering hot water that was measured at 124.1 and 125.2 degrees above the allowed range of 105-120 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The facility representative stated that the hot water heater will be turned down immediately and have the hot water measured on a daily basis for a period of 7-days. A statement of correction, along with the week long hot water readings, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in [1] out of [3] resident shower/bath areas did not have grab bars installed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The facility representative stated that the resident restroom and shower area will be equipped with grab bars prior to resident use. A statement of correction, along with receipts of the grab bar installation and pictures, will be completed and submitted into CCL by the due date.
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 11/21/2023 03:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ACCESS CARE CENTER
FACILITY NUMBER: 415600683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(4)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [4] facility staff file reviewed did not have proper fingerprint transfer to this facility number which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The facility representative stated that all facility staff files will be reviewed to make sure that they are properly fingerprint cleared and associated to this facility. A statement of correction, along with proof of the fingerprint transfer/association to this facility, will be completed and submitted into CCL by the due date.
Type A
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility resident files did not have an updated annual medical assessment completed to address any new dementia care needs which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2023
Plan of Correction
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The facility representative stated that all facility resident files will be reviewed to make sure that they are properly updated if diagnosed with dementia. A statement of correction, along with proof of the updated medical assessment, will be completed and submitted into CCL by the due date.
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 11/21/2023 03:17 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: ACCESS CARE CENTER
FACILITY NUMBER: 415600683

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several windows were either missing window screens or several had rips, tears, and holes in them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2023
Plan of Correction
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The facility representative stated that all window screens will be reviewed and any that are missing or have holes, rips, and tears in them will be repaired/replaced in order to be maintained in good repair at all times. A statement of correction, along with a receipt of the repair/replacement of the window screens with pictures, will be completed and submitted into CCL by the due date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in that several admission agreements were incomplete missing required signatures from the residents and their responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2023
Plan of Correction
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The facility representative stated that all resident files will be reviewed and all admission agreements will be updated to contain all required signatures from the residents and their responsible parties. A statement of correction, along with copies of the updated Admission Agreements, will be completed and submitted into CCL by the due date.
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie YangTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5