Community Care Licensing

Document Has Been Signed on 01/07/2025 05:37 PM - It Cannot Be Edited

FACILITY NAME:	JANIE'S HOME		FACILITY NUMBER:	415600809
ADMINISTRATOR/ DIRECTOR:	MURPHY, MAY MITZI		FACILITY TYPE:	740
ADDRESS:	197 FLYING CLOUD ISLE		TELEPHONE:	(650) 349-2943
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY: 6		CENSUS: 4	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Asst. Administrator, Shalmar Lardizabal		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

SUPERVISORS NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Type A

Section Cited

CCR

87303(e)(2)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). 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 based on observation, hot water temperature in the kitchen ad bathroom were measured at 139- 156 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure hot water temperature is within range, the plan shall include what action the facility will take to ensure compliance and what is the facility going to do to monitor hot water temperature on an on-going basis. In addition, the facility will monitor the hot water temperature from 1/8/2025- 1/15/2025 and submit the results to CCL by 1/16/2025.

Type A

Section Cited

CCR

87411(d)

(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: 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 based on record review, Staff #1 (S1) did not have proof that on-the- job training was completed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure S1 and all newly hired staff training is completed accordingly. In the plan, it shall indicate when S1 will be completing the required training. (no later than 1/14/2025). The administrator will submit a copy of the plan to CCL by 1/8/2025.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Type A

Section Cited

HSC

1569.69(a)(2)

(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
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Staff #1 did not have proof that this training was completed which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure this training is completed for S1 and all newly hired staff. In the plan, it shall indicate when S1 will be completing the required training. (no later than 1/14/2025). The administrator will submit a copy of the plan to CCL by 1/8/2025.

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 based on observation, record review and interview, the facility provided documentation indicating that the emergency and disaster drills were not completed accordingly which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure compliance and will submit a plan to CCL by 1/8/2025.

SUPERVISOR'S NAME: April Cowan LICENSING EVALUATOR NAME: Murial Han LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

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 3 out of 4 residents have bedrails 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: 01/08/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure a physician's order is obtained for the residents who have bedrails and in the plan, it shall indicate when an order will be obtained for all the residents. The administrator will provide a copy of the plan to CCL by 1/8/2025

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: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 facility did not have a current Liability Insurance which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	The administrator will provide a copy of the current Liability Insurance to CCL by 1/14/2025.

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: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
	VISIT DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Type A

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General This requirement is not met as evidenced by: Based on record review, Staff #1 (S1)'s health screen was incomplete
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on record review, Staff #1 (S1)'s health screen was incomplete which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/08/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure all staff's health screen is completed accordingly and the plan shall indicate the date that S1 will be completing the health screen process and the date shall be no later than 1/10/2025. The administrator will provide a copy of the plan to CCL by 1/8/2025.

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: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025

Link to Parent Document Below:

FACILITY NAME: JANIE'S HOME	FACILITY NUMBER: 415600809
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/07/2025

Type B

Section Cited

CCR

87458(a)

87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain documentation of a medical assessment, signed by a licensed medical professional acting within the scope of their practice and made within the last year, to be kept in the resident's record. 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 based on observation, interview and record review, 2 out of 4 residents did not have a current medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/14/2025
	Plan of Correction
1 2 3 4	The administrator will develop a plan to ensure all residents have a current medical assessment and the plan shall indicate the date of an updated medical assessment will be obtained for the residents identified.

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: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025