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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600808
Report Date: 11/08/2022
Date Signed: 11/08/2022 10:42:17 AM

Document Has Been Signed on 11/08/2022 10:42 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:ALWAYS TLCFACILITY NUMBER:
415600808
ADMINISTRATOR:CONSUNJI, TOMASFACILITY TYPE:
740
ADDRESS:226 SANDPIPER COURTTELEPHONE:
(650) 345-1441
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 6CENSUS: 3DATE:
11/08/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:caregiver, Adoracion MoresTIME COMPLETED:
10:50 AM
NARRATIVE
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On 11/8/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220817140116. LPA met with caregiver, Adoracion Mores and spoke to the administrator on the phone. LPA explained the purpose of the visit.

During the course of the investigation, the reporting party reported that the facility was not trained to care for resident #1 (R1) who suffered from advanced Dementia.

According to the administrator, staff was trained to provide care to residents with diagnosis of Dementia. However, the administrator was not able to provide on-the-job training records to show that staff was trained.

Based on complaint investigation, deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the administrator.

A copy of this report and the Appeal Rights are provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2022
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 11/08/2022 10:42 AM - It Cannot Be Edited


Created By: Murial Han On 11/08/2022 at 10:25 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: ALWAYS TLC
FACILITY NUMBER: 415600808

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87705(c)(3)(A)(B)(C)

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87705 Care of Persons with Dementia(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:(3) In addition to the on-the-job training requirements..staff who provide direct care to residents with dementia shall receive the following training...
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The administrator will review the regulation and submit a statement to CCL stating that it was reviewed. In addition, the administrator will provide in-services to staff pertaining to this regulation.
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A) Dementia care including,..(B) Recognizing symptoms..(C) Recognizing the effects of medications...this requirement is not met as the facility was not able to provide documents that facility staff has received this training while providing care to resident with Dementia which poses a potential health risk to residents in care.
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The administrator will provide a copy of the statement and a copy of the in-service sign-in record to CCL by the plan of correction due date of 11/18/2022

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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:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022


LIC809 (FAS) - (06/04)
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