415600735-7-28-2023-14-AS-GDOO-CU72KB-20230728172737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600735
Report Date: 07/28/2023
Date Signed: 07/28/2023 05:32:17 PM

Document Has Been Signed on 07/28/2023 05:32 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:	DOUBLE HAPPINESS CARE HOME		FACILITY NUMBER:	415600735
ADMINISTRATOR:	LAU, FLORDELIZA		FACILITY TYPE:	740
ADDRESS:	859 CAMARITAS CIRCLE		TELEPHONE:	(650) 993-4018
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS: 4	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Irene Mehta		TIME COMPLETED:	04:00 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	Licensing Program Analysts (LPAs) Grace Donato & Jaime Vado arrived unannounced to conduct the facility’s required 1 year annual inspection. LPAs met Designated Responsible person Irene Mehta and explained the purpose of the visit. During visit, LPAs toured the facility to include the resident bedrooms, bathrooms, kitchen, garage and exterior. During the tour on the outside of the facility, it was observed that there were empty water gallons on one of the exit pathways. It was immediately removed by staff so the path is now free of obstruction. Along the entrance fence, it was also observed that there were old beds and some paint buckets, it is already scheduled for pick up for disposal. All staff members present have been fingerprinted and associated in the facility except for the designated responsible person. Fire extinguishers are new and in working condition. The facility an operating carbon monoxide detector present. The was observed that the room temperature was at 73 deg F. Hot water was also tested in the bathrooms and the temperature was 120 deg F. Resident bedrooms and bathrooms were observed to be in good repair equipped with grab bars and non-skid mats. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. LPAs checked the food supply and there is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Facility doesn’t have an emergency drill log that should have been done quarterly. Facility doesn’t have a proper First Aid kit. It was observed that the first aid is not updated. There were several items that were expired and the wipes is dried out. 4 resident records and three staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility accepts hospice residents and are in compliance with the required waiver requirements.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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 07/28/2023 05:32 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: DOUBLE HAPPINESS CARE HOME	FACILITY NUMBER: 415600735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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 interview and record review, the licensee did not comply with the section cited above due to Facility not having an emergency drill log that should have been done quarterly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2023
	Plan of Correction
1 2 3 4	Licensee should submit a plan of action and conduct an in-serrvice training for emergency drill.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: DOUBLE HAPPINESS CARE HOME	FACILITY NUMBER: 415600735
	VISIT DATE: 07/28/2023

NARRATIVE

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Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

LPA interviewed 2 residents and 2 staff members. All staff are very competent with regards to the care of the residents.

LPA requested to submit the following by 8/4/2023:

LIC 500 Personnel Report

LPA received copy of Control of Property on 7/28/23.

Deficiencies are being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Irene Mehta and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/28/2023 05:32 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: DOUBLE HAPPINESS CARE HOME	FACILITY NUMBER: 415600735
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(8)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above due to Facility not having First Aid kit. It was observed that the first aid is not updated. There were several items that were expired which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/29/2023
	Plan of Correction
1 2 3 4	Immediately replace & update with new first aid kit. Send photos to Licensing once finished.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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