Community Care Licensing

Document Has Been Signed on 05/12/2023 04:39 PM - It Cannot Be Edited

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:	05/11/2023
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Randy Bandong		TIME COMPLETED:	04:35 PM

SUPERVISORS NAME: Cara Smith LICENSING EVALUATOR NAME: Jaime Vado LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023

Link to Parent Document Below:

FACILITY NAME: GONZALES HOME	FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/13/2023 Section Cited CCR 87355(e)(1)	1 2 3 4 5 6 7	CRIMINAL RECORD CLEARANCE 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, obtain a CA clearance or a criminal record exemption as required by the Department.	1 2 3 4 5 6 7	S1 cannot be on premises with contact with clients unless and until S1 has been fingerprinted and obtain criminal record clearance and association to the facility.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: S1 is not fingerprinted and not associated to the facility which pioses an immediate health and safety risk for residents in care. Civil penalty assessed at the reate of $100 a day x 5 days = $500	8 9 10 11 12 13 14
Deficiency Dismissed Type A 05/13/2023 Section Cited CCR87355(e)(2)	1 2 3 4 5 6 7	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: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)	1 2 3 4 5 6 7	Facility shall develop a plan in writing to ensure all staff are associated to the facility appropriately prior to working in the facility. Additionally proof of association to facility shall be submitted to the department for S1, S2, and S3.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on records reviewed during course of the investiagtion S1, S2, and S3 are not asociated to the faciilty which poses an immediate health and safety risk for residents in care. Civil penalty assessed at the rate of $100 for each staff person (S1, S2, S3) x 5 days = $1500	8 9 10 11 12 13 14

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Jaime Vado LICENSING EVALUATOR SIGNATURE: DATE: 05/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/11/2023

Link to Parent Document Below:

FACILITY NAME: GONZALES HOME	FACILITY NUMBER: 415600734
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/13/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements - (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.	1 2 3 4 5 6 7	Facility shall develop a plan of action to ensure that incident reports are completed and submitted to the Department within the regulation time frames for each occurence.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: The administrator/licensee failed to report to complete incident reports regarding the resident's condition to the Department.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

SUPERVISOR'S NAME: Cara Smith LICENSING EVALUATOR NAME: Jaime Vado LICENSING EVALUATOR SIGNATURE: DATE: 05/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2023