415600734-5-31-2023-14-AS-MHAN-CSCRPU-20230531131230

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600734
Report Date: 05/31/2023
Date Signed: 05/31/2023 06:04:29 PM

Document Has Been Signed on 05/31/2023 06:04 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:	GONZALES HOME		FACILITY NUMBER:	415600734
ADMINISTRATOR:	GONZALES, ROGELIO & PROSPE		FACILITY TYPE:	740
ADDRESS:	3645 FLEETWOOD DRIVE		TELEPHONE:	(650) 589-8820
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	05/31/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Pros Gonzales		TIME COMPLETED:	01:20 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 5/31/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers Randy Bandong and Blessie Bandong. Administrator Pros arrived shortly thereafter and assisted with the annual inspection. LPA explained the purpose of the visit. Administrator provided a tour of the facility and LPA observed the facility to be cleaned, tidy and in good repair. There are bedrooms (2 private and 2 share rooms), 2 full- bathrooms, kitchen, and common areas. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature was measured at 107-118 degrees F. Facility is equipped with smoke and carbon monoxide detectors. Fire extinguisher was last serviced on March 7, 2023. During the facility tour, LPA observed chemicals were locked, however, medication and sharps cabinets were not lock. LPA also observed 2 residents in bed with half siderail attached to their beds but there was no physician's order. According to administrator, the device is to assist resident with repositioning and facility will obtain physician's order for the half siderail. LPA conducted staff and resident interviews and file reviews. 4 resident records were reviewed and observed to have medical assessments signed by a medical professional. However, 4 out of 4 resident files did not have service needs/plan and 2 out of 4 resident files did not have pre-appraisal.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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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Document Has Been Signed on 05/31/2023 06:04 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: GONZALES HOME	FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation during the facility tour, LPA observed medication and sharps cabinets were not locked the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	The administrator will provide in-service to staff to ensure compliance. The licensee will submit a plan to ensure sharps and medication are locked and inaccessible to residents in care. The administrator will submit such plan and a copy of the staff in-service sign-in sheet to CCL by 6/2/2022.

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
1 2 3 4	Based on observation, interview and record review, the administrator was not able to provide any documentation that fire drill was conducted accordingly; the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	The licensee/administrator will conduct a fire drill with facility staff immediately and provide a copy of the sign-in sheet to CCL by 6/2/2023. In addition, the administrator/licensee will submit a plan to ensure the facility is in compliance with fire drill.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2023 06:04 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: GONZALES HOME	FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87456(a)(2)

Evaluation of Suitability for Admission

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record reviews, 2 out of 4 residents did not have a copy of the pre-admission appraisal in the resident files the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	The Licensee will review the regulation and provide a statement for the review to acknowledge the review, understanding and ensuring compliance. In addition, administrator will conduct an audit of all resident files to ensure compliance. Licensee and/or administrator will provide a copy of the statement and completed pre-appraisals to CCL by 6/7/2023.

Type B

Section Cited

HSC

1569.695(e)(2)

Other Provisions

(e) A facility shall have all of the following information readily available to facility staff during an emergency: (2) An appraisal of resident needs and services plan for each resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record reviews, LPA observed 4 out of 4 resident files did not include a service needs/plan the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	The Licensee will review the regulation and provide a statement for the review to acknowledge the review, understanding and ensuring compliance. In addition, administrator will conduct an audit of all resident files to ensure each resident has an individualized service needs/plan according to the care that is required.. Licensee and/or administrator will provide a copy of the statement and completed service needs/plan to CCL by 6/7/2023.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: GONZALES HOME	FACILITY NUMBER: 415600734
	VISIT DATE: 05/31/2023

NARRATIVE

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Staff members at the facility were fingerprint cleared and associated to the facility.

During the review of centrally stored medication, staff stated that they administered weekly glucose testing for residents.

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. A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/31/2023 06:04 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: GONZALES HOME	FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87628(a)

a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview, staff #1 stated that they administer glucose testing for residents every week the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/02/2023
	Plan of Correction
1 2 3 4	The licensee and/or administrator will submit a plan to ensure compliance with the above regulation.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

Page: 4 of 6

Document Has Been Signed on 05/31/2023 06:04 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: GONZALES HOME	FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87608(a)(3)

87608 Postural Supports (a) Based on the individual's preadmission appraisal, This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and observation, LPA observed 2 residents with siderail attached to their bed without a written physician's order indicating the need for the postural support, the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/07/2023
	Plan of Correction
1 2 3 4	The administrator/licensee will obtain a written physician's order for the siderail and provide a copy to CCL by 6/7/2023.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC809 (FAS) - (06/04)

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