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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600683
Report Date: 06/13/2024
Date Signed: 06/14/2024 09:26:16 AM


Document Has Been Signed on 06/14/2024 09:26 AM - 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:
06/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:49 PM
MET WITH:Caregiver, Ramon SarmientoTIME COMPLETED:
05:40 PM
NARRATIVE
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On June 13, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Ramon Sarmiento. The administrator, Cristina Hipolito arrived shortly thereafter and assisted with the inspection,

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility is clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four resident rooms( 2 private and 2 shared) and one caregiver room. LPA observed 2 bedridden residents are residing in a non-ambulatory room. Rooms were spacious and included all required furnishings. Three full bathrooms were observed to be clean; equipped with paper towels, soap, and grab bars. Extra linen was present. A tour of the garage area was conducted. Additional food storage units were observed to be present and in good repair at this time.

LPA observed medications, toxins and sharps were locked and inaccessible to residents. 2 days for perishables and & 7 days non-perishable were observed to be present.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were checked. Fire drill records were reviewed.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859 (The administrator certification is in the process of being renewed).

An immediate civil penalty of $500 dollars is being assessed today.

Based on observation, 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 administrator. A copy of this report and the appeal rights were provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
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 06/14/2024 09:26 AM - 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: 06/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 residents who are bedridden according to the physician's order are residing in a non-ambulatory room which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/14/2024.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the administrator was not able to provide proof that emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and will provide a copy of the plan to CCL by 6/14/2024.
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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2024
LIC809 (FAS) - (06/04)
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