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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600751
Report Date: 04/10/2023
Date Signed: 04/10/2023 10:21:42 AM


Document Has Been Signed on 04/10/2023 10:21 AM - 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:HOME AT CRESTMOORFACILITY NUMBER:
415600751
ADMINISTRATOR:PRADO, IMELDAFACILITY TYPE:
740
ADDRESS:2600 PLYMOUTH WAYTELEPHONE:
(650) 872-8419
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 4DATE:
04/10/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Caregiver, Krisanta MercadoTIME COMPLETED:
10:30 AM
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On 4/10/2023, Licensing Program Analyst (LPA) Murial Han and Licensing Program Analyst (LPA) Grace Donato conducted a case management visit concerning an incident that was reported by the facility. LPAs explained the purpose of today's visit.

On 4/3/2023, facility submitted an incident report concerning resident #1 (R1) was sitting at the dining table and caregiver noted an empty bottle of medication in the sink that did not belong to R1.

During today's visit, LPAs observed medications to be locked and inaccessible to residents; there was medication stored in the refrigerator placed in a locked container. In addition, LPA observed R1 sitting in the living room, and watching TV.

In regards to the incident, caregiver stated that on the day when it occurred, staff #1 (S1) was preparing medication for resident #2 (R2) in the dining room area while R1 was present, and sitting in the dining room table. The caregiver needed to use the bathroom so caregiver placed R2's medication in the refrigerator that was not locked and upon returned, caregiver noticed an empty bottle of medication of R2 in the sink and appeared to be ingested by R1.

Caregiver called the paramedics and was transferred to poison control. Subsequently, the administrator instructed staff to take R1 to the hospital for further evaluation. R1 returned on the same day.

Deficient is cited today as the facility did not ensure centrally stored medicines in a safe and locked place that is not accessible to person(s) in care.

SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HOME AT CRESTMOOR
FACILITY NUMBER: 415600751
VISIT DATE: 04/10/2023
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Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with caregiver, Krisanta Mercado and administrator Imeda Prado. A copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/10/2023 10:21 AM - 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: HOME AT CRESTMOOR
FACILITY NUMBER: 415600751

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2023
Section Cited

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87465
Incidental Medical and Dental Care..(h) The following requirements shall apply to medications which are centrally stored:..(2)Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons..
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The licensee and/or administrator will review the regulation, develop a plan to ensure this incident does not happen again. The plan needs to include routine checks to ensure centrally stored medication is in a
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This requirement is not met as evidenced by caregiver did not ensure R2's medication was locked and not accessible to residents which resulted R1 ingested and was transferred to hospital which posed an immediate health risks for residents in care.
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safe and locked place that is inaccessible to residents in care. In addition, the plan needs to include staff training. The administrator/licensee will provide a copy of such plan and a sign-in record of staff training to CCL by 4/11/2023.

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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
LIC809 (FAS) - (06/04)
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