Community Care Licensing

Document Has Been Signed on 10/15/2024 05:59 PM - It Cannot Be Edited

FACILITY NAME:	AMAZING HOME		FACILITY NUMBER:	415600801
ADMINISTRATOR/ DIRECTOR:	CONDE, NECIA&SALVADOR,LEAN		FACILITY TYPE:	740
ADDRESS:	17 JODY COURT		TELEPHONE:	(650) 286-9698
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94402
CAPACITY: 6		CENSUS: 5	DATE:	10/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:45 PM
MET WITH:	Necia Conde, Iress Caguiat, Lea Salvador		TIME VISIT/ INSPECTION COMPLETED:	06:00 PM

SUPERVISORS NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024

Link to Parent Document Below:

FACILITY NAME: AMAZING HOME	FACILITY NUMBER: 415600801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

Type A

Section Cited

CCR

87309(a)

(a) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as spray sanitizer--labeled Keep out of Reach of Children--is stored in room of client #5, Comet liquid cleanser stored in common bathroom, wood cleaner stored in linen closet. All cleaners are accessible to clients. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Cleaning products were made inaccessible to clients by removing to locked storage cabinet in LPA's presence. Deficiency corrected and cleared.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024

Link to Parent Document Below:

FACILITY NAME: AMAZING HOME	FACILITY NUMBER: 415600801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

Type B

Section Cited

CCR

87303(e)(4)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 out of 2 client bathrooms observed, which poses a potential health, safety or personal rights risk to persons in care. - In private bathroom in master bedroom, there are no grab bars in shower stall and toilet.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Grab bars will be installed in private bathroom for shower and toilet. Proof of correction to be sent to CCLD BY DUE DATE.

Type B

Section Cited

CCR

87506(b)(15)

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of clients' records, the licensee did not comply with the section cited above in 3 out of 5 client records reviewed, which poses a potential health, safety or personal rights risk to persons in care. - Monthly rate for basic services is not included on Admission Agreements for clients #1, #4, #5, who are place by Institute on Aging. The "IOA Agreement for Financial Responsibility as part of Community Care Settings Program"--which specifies monthly rates--is not maintained for these 3 residents.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	The signed and dated IoA Agreements for 3 clients will be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024

Link to Parent Document Below:

FACILITY NAME: AMAZING HOME	FACILITY NUMBER: 415600801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

Type B

Section Cited

CCR

87457(c)

(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on review of clients' records, the licensee did not comply with the section cited above in 1 out of 6 client files reviewed, which poses a potential health, safety or personal rights risk to persons in care. - There is no pre-admission appraisal/needs and services plan for client #5, who was admitted 2/2023.
	POC Due Date: 10/15/2024
	Plan of Correction
1 2 3 4	Needs and Services Plan for client #5 was completed in LPA's presence. Defiency corrected and cleraed. Appraisals for all clients shall be maintained and completed in order to adequately create a Needs and Services Plan.

Type B

Section Cited

HSC

1569.695(c)

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility records review, the licensee did not comply with the section cited above, as the most recent disaster drill was documented in December 2023. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Disaster drills shall be conducted at least quarterly, and documented. Proof of correction to be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024

Link to Parent Document Below:

FACILITY NAME: AMAZING HOME	FACILITY NUMBER: 415600801
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/15/2024

Type B

Section Cited

CCR

87411(f)

PERSONNEL REQUIREMENTS - GENERAL All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health. Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on staff records review, the licensee did not comply with the section cited above in 3 out of 6 staff files reviewed, which poses a potential health, safety or personal rights risk to persons in care. There is no health screening and/or TB test result on file for staff #3, #5, #6.
	POC Due Date: 10/29/2024
	Plan of Correction
1 2 3 4	Health screenings and/or TB test results for staff #3, #5, #6 will be sent to CCLD BY DUE DATE.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Audrey Jeung LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024