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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600809
Report Date: 01/10/2024
Date Signed: 01/10/2024 05:03:33 PM

Document Has Been Signed on 01/10/2024 05:03 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:JANIE'S HOMEFACILITY NUMBER:
415600809
ADMINISTRATOR:MURPHY, MAY MITZIFACILITY TYPE:
740
ADDRESS:197 FLYING CLOUD ISLETELEPHONE:
(650) 349-2943
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 6CENSUS: 4DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Assistant Administrator, Shalimar LardizabalTIME COMPLETED:
12:30 PM
NARRATIVE
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On January 10, 2024 Licensing Program Analyst (LPA) Murial Han conduct an annual inspection. LPA met with assistant administrator and explained the purpose of today's visit.

Assistant administrator provided a tour of the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is single story facility with 5 resident bedrooms and one of them being shared room that is currently occupied by one resident. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and nonskid mats. Facility temperature is comfortable.

During the tour, LPA observed an Accessory Dwelling Unit (ADU) in the garage with a bed, table, TV and other furniture. This ADU is not part of the facility sketch on record. According to the assistant administrator it was build in 2019 without a proper permit.

Chemicals, toxins, sharps and medications are observed to be unlocked and accessible to residents in care.

Centrally stored medication was reviewed and observed 4 out of 4 residents did not have a centrally stored medication record.

2 days of perishables and 7 days of nonperishable foods were observed for the residents.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire drill records reviewed.

Hot water temperature through-out the facility is measured at 108- 115 degrees F.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/10/2024
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 7
Document Has Been Signed on 01/10/2024 05:03 PM - It Cannot Be Edited


Created By: Murial Han On 01/10/2024 at 11:17 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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305(a)
Alterations to Existing Buildings or New Facilities
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, record review and interview the licensee did not comply with the section cited above as LPA observed an Accessory Dwelling Unit (ADU) as living space in the garage without a proper permit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The Licensee/administrator will remove all the furniture in the ADU and send photo(s) to proof that it was completed by 1/11/24. In addition, administrator/licensee will provide a plan to ensure compliance.
Type A
Section Cited
CCR
87309(a)
Storage Space
(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
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Based on observation and interview the licensee did not comply with the section cited above as sharps and chemicals were not locked and accessible to resident in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure compliance and will send photos to ensure locks are installed on the storage areas for the chemicals and sharps.
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: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
Page: 2 of 7
Document Has Been Signed on 01/10/2024 05:03 PM - It Cannot Be Edited


Created By: Murial Han On 01/10/2024 at 11:17 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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above as 4 out of 4 residents did not have Centrally Stored Medication Record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The administrator/licensee will provide a copy of the completed centrally stored medication record for all 4 residents by 1/11/2024.
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(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
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Based on observation, record review and interview the licensee did not comply with the section cited above as drills were not completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The administrator/licensee will submit a plan of compliance and provide a copy of the plan to CCL by 1/11/2024.
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: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 01/10/2024 05:03 PM - It Cannot Be Edited


Created By: Murial Han On 01/10/2024 at 11:17 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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(3)
Postural Supports
(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
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Based on observation, record review and interview the licensee did not comply with the section cited above as 3 out of 4 resident's appraisals were not signed by the facility representative and applicant and responsible party which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The administrator/licensee will provide a copy of the signed and dated appraisal service needs and plans for all 3 residents to CCL by 1/11/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
Page: 4 of 7
Document Has Been Signed on 01/10/2024 05:03 PM - It Cannot Be Edited


Created By: Murial Han On 01/10/2024 at 11:17 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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above as staff #1 (S1) did not have documents to proof that the initial training was completed prior to working which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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The administrator/licensee will provide a copy of staff #1's required training record to CCL by 1/17/2024.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview the licensee did not comply with the section cited above as 1 out of 4 resident's appraisal service needs and plan was incomplete which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/17/2024
Plan of Correction
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The administrator/licensee will provide a copy of the completed appraisal service needs and plan to CCL by 1/17/2024.
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: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 01/10/2024 05:03 PM - It Cannot Be Edited


Created By: Murial Han On 01/10/2024 at 11:38 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: JANIE'S HOME
FACILITY NUMBER: 415600809

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview the licensee did not comply with the section cited above as medications were observed in the living room to be unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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The administrator/licensee will provide a plan to ensure compliance to CCL by 1/11/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024


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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: JANIE'S HOME
FACILITY NUMBER: 415600809
VISIT DATE: 01/10/2024
NARRATIVE
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LPA reviewed 4 resident records and all of them contained admission agreement, medical assessment- LIC 602 (Physician Order), Resident Rights, Resident Identification information. However, 1 out of 4 resident's Appraisal Needs and Service Plan was incomplete, and 3 out of 4 resident's Appraisals were not signed and dated by the facility representative and the applicant or the responsible party.

LPA reviewed 3 staff files and all of them contained personnel records, TB screening, First Aide/CPR, Criminal Record Statement, fingerprint cleared and associated to the facility and training records except for staff #1(S1) who did not have the initial training records.

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 with the asst. administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC809 (FAS) - (06/04)
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