415600821-9-27-2021-14-AS-AJEG-C7A2QX-20210927173639

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600821
Report Date: 09/27/2021
Date Signed: 09/27/2021 05:36:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	HOME SWEET HOME SENIOR CARE		FACILITY NUMBER:	415600821
ADMINISTRATOR:	NEDILJKA MATIJAS		FACILITY TYPE:	740
ADDRESS:	1560 BRYANT STREET		TELEPHONE:	(650) 992-2727
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	55	CENSUS: 36	DATE:	09/27/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Iren Ludnay		TIME COMPLETED:	05:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Audrey Jeung toured facility and grounds, consisting of private and shared studio units--all but one with private shared bathrooms--on 2 floors. There are 13 rooms on the second floor and 15 rooms on the ground floor, where there are 4 exits equipped with a 15 second delayed egress: one is tested and operates as required. The front gate is a delayed egress, but the front door is not. The facility accommodates non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room, kitchen, offices and all purpose room on the ground level. Beauty salon is located on second floor. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap and paper towels are available in all bathrooms, including private client bathrooms and in kitchen. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Iren Ludnay is a certified RCFE administrator (x 4/22) that oversees facility operations. The following updated licensing forms or information are requested to be submitted to CCLD BY 10/11/21: - Administrative Organization (LIC309) - Affidavit Regarding Client Cash Resources (LIC400) - Proof of current surety bond - Program plan for serving bedridden residents - Proof of current liability insurance COVID Mitigation Plan is provided to LPA today. This may have been submitted to CCLD previously. Deficiency of the CA Code of REgulations, Title 22 is observed and cited on a following page.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HOME SWEET HOME SENIOR CARE	FACILITY NUMBER: 415600821
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

Personnel Requirements - General

(f) 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 record review with administrator, the licensee did not comply with the section cited above in 3 out of 4 staff files reviewd, which poses a potential health, safety or personal rights risk to persons in care. Out of 4 caregivers, there are 3 that do not have health screenings on file. Two of the 3 staff--E.S. and R.A.--have current TB test results, but no health screening. One staff--S.Y.--does not have health screening and TB test result on file.
	POC Due Date: 10/11/2021
	Plan of Correction
1 2 3 4	Plan of correction to be submitted to CCLD BY DUE DATE, which will include copies of health screenings for staff R.A., E.S. and S.Y., as well as TB rest result for staff S.Y.

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: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC809 (FAS) - (06/04)

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