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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600742
Report Date: 07/08/2024
Date Signed: 07/08/2024 06:13:57 PM


Document Has Been Signed on 07/08/2024 06:13 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:PATRICIA HOMEFACILITY NUMBER:
415600742
ADMINISTRATOR:NAVARRO, AURELIAFACILITY TYPE:
740
ADDRESS:988 PATRICIA AVENUETELEPHONE:
(650) 347-3870
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
07/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Irene LaguaTIME COMPLETED:
06:15 PM
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LPA Audrey Jeung toured facility and grounds of this RCFE for developmentally disabled elderly. No accessible bodies of water or fire safety hazards are observed. There are 3 shared bedrooms for residents and 2 bathrooms--one designated for residents. As per San Mateo Fire Dept.(5/2010), exit doors in bedrooms are not required to be exits. In addition, there are 2 staff rooms for 4 live-in staff. There is a detached storage shed in backyard. Washer and dryer are located in one car attached garage.
Staff confirmed that facility is currently COVID free. PPE and food supplies are adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Soap and paper towels are present in bathrooms and kitchen sink. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 2 residents present, and 3 staff; other clients are participating in day programming off site. Criminal record clearances or exemptions for facility staff or other individuals who have client contact are reviewed, as well as other staff and client records. Aurelia Navarro is a certified RCFE administrator (x 9/25) that oversees facility operations.

The following forms/information are requested to be updated and submitted to CCLD by 7/22/24:
- Administrative Organization (LIC309)
- Designation of Administrative Responsibility (LIC308)
- Personnel REport (LIC500)
- Emergency Disaster Plan (LIC610 revised 9 page version)
- Facility Sketch (LIC999)
- Control of property (recorded grant deed and current signed lease)

Proof of current liability insurance is given to LPA today.

Deficiency of the General Licensing Regulations, of the California Code of Regulations, Title 22, Division 6, is cited. Also see Technical Advisory Notes--5 pages--for additional information.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
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 07/08/2024 06:13 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PATRICIA HOME
FACILITY NUMBER: 415600742

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.39(b)
Regulations
(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of foot wound and absence of documentation of home health, the licensee did not comply with the section cited above, as staff who are not medical professionals perform wound care for client #1. There is no documentation that staff received training on caring for foot wounds of client #1, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Administrator to submit plan of correction to address ongoing care of foot wounds of client #1, which shall include either MD care plan for home health visits to provide wound treatment or exception request to allow trained staff to perform wound care.
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 CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2024
LIC809 (FAS) - (06/04)
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