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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600693
Report Date: 10/22/2024
Date Signed: 10/22/2024 08:53:28 PM

Document Has Been Signed on 10/22/2024 08:53 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:AM RESIDENTIAL CARE HOMEFACILITY NUMBER:
415600693
ADMINISTRATOR/
DIRECTOR:		EISEMAN, KATIEFACILITY TYPE:
740
ADDRESS:1000 BALBOA AVENUETELEPHONE:
(650) 348-8212
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
10/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Lead Caregiver, Rosita PadolinaTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 10/22/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon entrance, LPA met with caregivers Imelda Silo and Zenaida Tarrazona and LPA explained the purpose of the visit. Caregivers contacted the lead caregiver, Rosita Padolina of LPA's inspection who arrived shortly thereafter as well as the administrator, Katie Eiseman.

The facility is licensed for a capacity of 6 non-ambulatory residents of which 3 may receive hospice care services. There are 3 residents receiving hospice services at this time.

LPA toured the facility inside and outside including the bedrooms (4 private and 1 shared rooms), 2 full- bathrooms, kitchen, living room and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and in good condition. Facility temperature is comfortable. Hot water temperatures in the kitchen and bathroom was measured at 105- 110 degrees F. LPA observed 2-day perishables and 7-day non-perishables.

LPA observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors in the facility. Fire extinguishers were last inspected on 8/8/2024.

Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents.

A review of (6) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859

During the tour of the facility, LPA observed a table, folding chairs and personal belongings in the garage and according to staff, the garage is being used as staff breakroom.

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 the administrator. A copy is provided and the appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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 10/22/2024 08:53 PM - It Cannot Be Edited


Created By: Murial Han On 10/22/2024 at 12:55 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: AM RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)

87608 Postural Supports

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 5 out of 6 residents have bedrails by the head of the bed with a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and on the plan, it shall indicate the date that a physician's order will be obtained for the bedrails. The administrator will submit a copy of the plan to CCL by 10/23/2024 and a copy of the physician's order on the date that is indicated on the plan of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/22/2024 08:53 PM - It Cannot Be Edited


Created By: Murial Han On 10/22/2024 at 01:01 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: AM RESIDENTIAL CARE HOME
FACILITY NUMBER: 415600693

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(a)
87307 Personal Accommodations and Services

This requirement is not met as evidenced by: LPA observed a table, folding chairs and personal belonings in the garage and according to staff, it is being used as a staff breakroom.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed a table, folding chairs and personal belongings in the garage and according to staff, it is being used as a staff breakroom. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/29/2024
Plan of Correction
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The administrator will develop a plan to ensure the garage is being used as a garage according to the facility sketch and will provide photos to CCL to proof that the garage is revert to a garage. The administrator will provide a copy of the plan and photos to CCL by 10/29/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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