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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600755
Report Date: 04/22/2024
Date Signed: 04/24/2024 08:33:39 AM

Document Has Been Signed on 04/24/2024 08:33 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:J AND V FAMILY CARE HOMEFACILITY NUMBER:
415600755
ADMINISTRATOR/
DIRECTOR:		ANDAYA, JULITA DFACILITY TYPE:
740
ADDRESS:329 SAN PABLO AVENUETELEPHONE:
(650) 952-5231
CITY:MILLBRAESTATE: CAZIP CODE:
94030
CAPACITY: 6CENSUS: 5DATE:
04/22/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Lynn Alfafara and Jaime Escarez, Julita AndayaTIME VISIT/
INSPECTION COMPLETED:
07:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. Hot water temperature is tested. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff records. Julita Andaya is a certified RCFE administrator (x 2/25) that oversees facility operations. Client files are reviewed, including medications, which are recorded on Centrally Stored Medications Records.

The following forms are requested to be updated and returned to CCL by 4/29/24:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610D Emergency Disaster Plan
• Proof of current liability insurance
- Infection Control Plan

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Also, see Advisory Notes--7 pages--for technical violations to be addressed.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 04/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2024
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 04/24/2024 08:33 AM - It Cannot Be Edited


Created By: Audrey Jeung On 04/22/2024 at 06:03 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of medications in kitchen cabinet, the licensee did not comply with the section cited above, as 2 out of 5 residents' medications are prepared 7 days in advance. Pills are observed in 7-day plastic pill dispenser. This poses a potential health, safety or personal rights risk to persons in care.
Medicatiions for clients #1 and #3 are prepared 7 days in advance.
POC Due Date: 04/29/2024
Plan of Correction
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This practice must stop immediately. Plan/proof of correction to be submitted to CCLD BY DUE DATE.
Type B
Section Cited
CCR
87307(a)
PERSONAL ACCOMMODATIONS AND SERVICES
Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as staff are sleeping in garage. There is a makeshift bed in garage and personal items of staff. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/29/2024
Plan of Correction
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Garage cannot be used as sleeping quarters. Plan/proof of correction to be sent to CCLD BY DUE DATE.
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 Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/24/2024 08:33 AM - It Cannot Be Edited


Created By: Audrey Jeung On 04/22/2024 at 06:23 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: J AND V FAMILY CARE HOME
FACILITY NUMBER: 415600755

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
MAINTENANCE AND OPERATION
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as hot water temperature in clients' bathroom tested at 129 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Hot water temperature will be lowered and maintained between 105 and 120 degrees. Proof of correction to be sent to CCLD BY DUE DATE.
Type A
Section Cited
CCR
87468.1
PERSONAL RIGHTS


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as both wood gates that lead from backyard to street are locked. This poses an immediate health, safety or personal rights risk to persons in care.
One gate is secured with a padlock. The other has 2 nails driven into the wood post so gate cannot be opened.
Per staff, gates were secured to prevent a resident from wandering out of facility.
in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Padlock hardware was removed from one gate nails were removed from the other gate. Administrator to ensure that gates remain accessible. Plan of correction to be submitted to CCLD BY DUE DATE.
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 Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2024


LIC809 (FAS) - (06/04)
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