415600744-12-24-2023-14-AS-VBRN-CYTTLX-20231224135016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600744
Report Date: 12/24/2023
Date Signed: 12/24/2023 01:50:30 PM

Document Has Been Signed on 12/24/2023 01:50 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:	APPLE TREE HOME CARE		FACILITY NUMBER:	415600744
ADMINISTRATOR:	HUANG, WENSHU		FACILITY TYPE:	740
ADDRESS:	716 NORTH HUMBOLDT STREET		TELEPHONE:	(650) 376-3389
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94401
CAPACITY:	6	CENSUS: 5	DATE:	12/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Joebellema Payumo		TIME COMPLETED:	02:00 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 Analyst (LPA) Victoria Brown arrived unannounced on 12/24/23 at 10:00am to conduct a Required -1 Year visit. LPA met with Joebellema Payumo and stated the purpose of the visit. Administrator certificate expires 1/11/24 for Lilia Mauricio. LPA was allowed entry into the facility that is licensed to serve 6 non-ambulatory residents of which 5 may receive hospice care services. At this time there are 0 residents receiving hospice care services. Annual Fees are current. The Facility staff roster provided during this visit. LPA observed the Infection Control Plan during this visit. The last documented emergency drill was conducted on 11/26/23. During this visit several families arrived to visit with residents. LPA observed residents participating in individual activities. LPA observed the medications area to be locked. LPA observed a pull alarm fire system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and antiseptic solution. LPA observed 2 staff and 2 resident files and conducted interviews during this visit. The Department is aware there is a pending Change of Ownership (TLC Home Care), however, upon a file review the following items were discussed to be submitted with any changes annually for this facility: Infection Control Plan (LIC9282), Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Emergency Disaster Plan (LIC610E), Liability Insurance. See 809C for continuation...

SUPERVISOR'S NAME: Victoria Brown	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2023

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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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: APPLE TREE HOME CARE	FACILITY NUMBER: 415600744
	VISIT DATE: 12/24/2023

NARRATIVE

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809 Continued...

LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The temperature inside the facility was observed to be at 75*F which is within the required range of 68-85*F. The hot water temperature was measured at 117.4 *F which is within the required range of 105-120*F.

LPA observed 2-day perishables. LPA took a photo of 2 cans of corn, 1 can of peaches, 4 cans of tuna, 2 cans of beans, 1 large can of chicken noodle soup and 1 large can of cream of mushroom, 3 cans of tomato soup and 1 can of clam chowder. The preponderance of evidence was met that there is not a supply of nonperishable foods for a minimum of one week maintained on the premises.

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed.

The facility representative was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.

SUPERVISOR'S NAME: Victoria Brown	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/24/2023 01:50 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: APPLE TREE HOME CARE	FACILITY NUMBER: 415600744
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(26)

This requirement is not met as evidenced by: LPA did not observe a supply of nonperishables maintained on premises.
	Deficient Practice Statement
1 2 3 4	Based on observation and confirmation of representative there are no other nonperishables on the premises, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/25/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator shall ensure 7 day perishables are maintained on premises at all times. A letter of confirmation shall be faxed to the office that food is present in the facility as stated in the regulations. POC due by due date 12/25/23.

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: Victoria Brown	TELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Victoria Brown	TELEPHONE: (209) 814-1955
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2023

LIC809 (FAS) - (06/04)

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