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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600769
Report Date: 08/04/2021
Date Signed: 08/04/2021 01:39:08 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:LYONS ELDERLY HOME LLCFACILITY NUMBER:
415600769
ADMINISTRATOR:JAVIER, JOSEPHINEFACILITY TYPE:
740
ADDRESS:1168 LYONS STREETTELEPHONE:
(650) 556-1754
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 2DATE:
08/04/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mayanne AvenaTIME COMPLETED:
02:00 PM
NARRATIVE
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On 08/04/2021 at 1100hrs Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced prelicensing inspection visit. LPA met with licensee/administrator Mayanne and explained purpose of today's inspection.

During today's inspection LPA toured the facility inside and out. This is a single story facility. Ambient temperature is observed as 72F. Fire lanes are clear on the outside of the facility. All resident bathrooms are inspected. Of the three, two do not have fully functioning faucets. Bathroom in main hallway does not produce hot water and knobs do not allow free flowing water. Bathroom in resident room faucet does not function at all but toilet and shower are operable. Main bathroom adjacent to living room is considered the main shower and bathroom. Faucet and shower functions appropriately. Water is tested at 125F at this time. 48hr fresh food supply is present. There are two freezers present as well and supplies are in place. Two week canned and dried goods are observed as in place. Resident bedrooms have all required furniture in place. Linens are observed as in place. Medications are locked and secured in office area. First aid kit is complete. Fire extinguishers are in place and fully charged. Fire alarms are hardwired in place and carbon monoxide detector is observed as plugged in adjacent to the kitchen. Cleaning solutions are observed as stored in hallway closet but is not locked. Backyard had boxes of items that are in the process of being moved. Main dining table has paperwork and files that need organizing. Resident and staff files require organization. Facility floors do have areas with debris and foot prints from water near bathroom adjacent to living room. Areas in facility observed as well with dusty and spider webs. Resident files are reviewed as current but require updated admission agreements reflecting new facility. Fire drill log was not able to be reviewed. Facility does not handle cash resources of residents. Administrator certificate is current expiring on 8/5/2022.

The following updated forms are to be received by 08/20/2021:
LIC500
LIC308
LIC610E
Copy of current administrator certificate

Deficiencies of the California Code of Regulations, Title 22, citations appear on the following page.

Report is reviewed with administrator/licensee.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LYONS ELDERLY HOME LLC
FACILITY NUMBER: 415600769
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2021
Section Cited

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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).
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This requirement has not been met as evidenced by: Hot water temperature was measured at 125F in bathroom adjacent to living room.
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POC due by due date
Type A
08/05/2021
Section Cited

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Storage Space - Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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This requirement has not been met as evidenced by: Cleaning solutions are observed in the wallway closet did not have a locking mechanism installed at time of inspection.
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POC due 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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: LYONS ELDERLY HOME LLC
FACILITY NUMBER: 415600769
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/20/2021
Section Cited

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Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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This requirement has not been met as evidenced by: LPA observed debris on the floors through out facility, dried water foot prints near living room bathroom, water faucets in resident room and hallway bathroom do not function properly not allowing appropriate water flow. Areas around faciilty observed with dust and spider webs.
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POC due by due date
Type B
08/20/2021
Section Cited

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Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement has not been met as evidenced by: LPA requested to view fire drill log but the log was not able to be found and licensee could not provided exact date of last drill conducted.
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POC due 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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3