Community Care Licensing

Document Has Been Signed on 08/06/2024 07:33 PM - It Cannot Be Edited

FACILITY NAME:	ALWAYS TLC		FACILITY NUMBER:	415600808
ADMINISTRATOR/ DIRECTOR:	CONSUNJI, TOMAS		FACILITY TYPE:	740
ADDRESS:	226 SANDPIPER COURT		TELEPHONE:	(650) 345-1441
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY: 6		CENSUS: 6	DATE:	08/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Caregiver, Adoracion Mores		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

SUPERVISORS NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

CCR

87470(b)(2)

(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed that there was no gowns available at the facility while caring for a resident who has a contagious disease which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure appropriate PPE is available at all times to ensure the safety of staff, residents and visitors.The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a unit was built in the garage and according to the San Mateo Consolidated Fire Department and Foster City Building permit, there was no records of a building permit was obtained which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to indicate the steps that the facility will take to be in compliance with the unit in the garage. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

CCR

87305(a)

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a unit was built in the garage and according to the San Mateo Consolidated Fire Department and Foster City Building permit, there was no records of a building permit was obtained which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to indicate the steps that the facility will take to be in compliance with the unit that was built in the garage without a building permit. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Type A

Section Cited

CCR

87307(d)(6)

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed outdoor passageway was blocked by the wooden fence and stored many medical devices and other objects which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure passageways are free of obstruction. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Section Cited

	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above 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:
	Plan of Correction
1 2 3 4

Type A

Section Cited

CCR

87456(a)(2)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 6 residents did not have a pre-admission appraisal which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/08/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure pre-admission appraisal is obtained prior to resident's admission. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

CCR

87458(a)

(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 1 out of 6 resident did not have a completed medical assessment/LIC602 on file which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure all the residents have a documentation of a medical assessment, signed by a physician on file. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Type A

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 [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide any documents that emergency drills were completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to indicate when a drill will be conducted and how often it will be performed moving forward. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type A

Section Cited

CCR

87608(a)(3)

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 out of 6 residents with bed rails by the head of the bed without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to indicate when a physician's order will be obtained for the device that is being used and will provide a copy of the physician's orders when obtained. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

Type A

Section Cited

CCR

87608(a)(5)(B)

(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 4 out of 6 residents have bed rails by the head and foot of the bed and according to the staff, these residents are not on hospice which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/07/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure compliance. The administrator/licensee will provide a copy of the plan to CCL by 8/7/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

HSC

1569.625(b)(2)

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 1 staff did not have any training records for 2023 and 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to indicate when training will be completed for this staff and on the plan, it shall indicate what steps the facility will take to prevent this from happening again. The administrator/licensee will provide a copy of the plan to CCL by 8/13/2024.

Type B

Section Cited

CCR

87506(b)(17)(E)

(b) Each resident's record shall contain at least the following information: (17) Documents and information required by the following: (E) Section 87463, Reappraisals; and This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 6 out of 6 residents did not have a copy of the reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to indicate when the reappraisals will be completed for all the residents and will provide a copy of the completed reappraisals. The administrator/licensee will provide a copy of the plan to CCL by 8/13/2024.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

Link to Parent Document Below:

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2024

Type B

Section Cited

CCR

87456(a)(3)

(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed resident with diagnosis of dementia did not have a recent medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/13/2024
	Plan of Correction
1 2 3 4	The administrator will develop a plan to indicate when an updated medical assessment will be completed for the residents who are diagnosed with Dementia. The administrator/licensee will provide a copy of the plan to CCL by 8/13/2024.

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: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024

FACILITY NAME: ALWAYS TLC	FACILITY NUMBER: 415600808
	VISIT DATE: 08/06/2024