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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600789
Report Date: 04/08/2025
Date Signed: 04/08/2025 04:49:10 PM

Document Has Been Signed on 04/08/2025 04:49 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:TOYON CARE LLCFACILITY NUMBER:
415600789
ADMINISTRATOR/
DIRECTOR:		WEI, ANGELA Y.FACILITY TYPE:
740
ADDRESS:1000 TOYON DRIVETELEPHONE:
(415) 606-6829
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
04/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Val QuirosTIME VISIT/
INSPECTION COMPLETED:
11:40 AM
NARRATIVE
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On April 8, 2025 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Val Quiros and Lai Chun Chan. LPA explained the purpose of the visit. Caregiver Val Quiros called and informed the administrator of today's inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort.

During the tour of the backyard, LPA observed a shed that was not on the facility sketch and in the shed, there was a bed, a table, and other personal items. LPA also observed construction in progress next to the Shed. According to the administrator, the shed is currently being used as a livable space for one of the caregivers and they are building a bathroom next to the shed. The administrator stated that the facility did not obtain a permit for the construction.

LPA observed 6 resident rooms with all private rooms. Rooms were spacious and included all required furnishings. Bathrooms #1 and #2 were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. However, bathroom #3 had a strong urine odor, the toilet and the floor were dirty. Hot water temperature in the kitchen, and bathroom was measured at 108- 111 degrees F. 2 days for perishables and & 7 days non-perishable were observed to be present.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/08/2025 04:49 PM - It Cannot Be Edited


Created By: Murial Han On 04/08/2025 at 10:56 AM
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: TOYON CARE LLC
FACILITY NUMBER: 415600789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed construction in the backyard, and there is a shed next to the construction that was not identified on the facility sketch which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
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The administrator will develop a plan of correction to ensure compliance. The administrator will revise the facility sketch to reflect the facility's floor plan both indoor and outdoor of the facility. In addition, the facility sketch shall indicate the usage of the shed in the back yard. The administrator will provide a copy of the signed and dated plan of correction to CCL by 4/9/2025 and a copy of the revised facility sketch by 4/15/2025.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed sharps in the kitchen not locked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide photo(s) to proof all sharps are locked and inaccessible to residents in care. The administrator will provide a plan of correction to CCL by 4/8/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 04/08/2025 04:49 PM - It Cannot Be Edited


Created By: Murial Han On 04/08/2025 at 10:56 AM
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: TOYON CARE LLC
FACILITY NUMBER: 415600789

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) 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.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed bathroom #3 by the kitchen had a strong odor smell, the toilet and the floor surface were dirty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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The administrator will develop a plan to ensure bathroom #3 is clean and will provide a copy of the plan of correction to CCL by 4/15/2025. The administrator will provide photos of the bathroom with the plan of correction.
Type B
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by:87307 Personal Accommodations and Services.(a) 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.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed caregiver resides in a shed in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan of correction to CCL by 4/15/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
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: TOYON CARE LLC
FACILITY NUMBER: 415600789
VISIT DATE: 04/08/2025
NARRATIVE
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Facility is equipped with smoke detectors and carbon monoxide detectors. Fire drill records were reviewed.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed caregiver, Val Quiros. A copy is provided with the appeal rights.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2025
LIC809 (FAS) - (06/04)
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