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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600832
Report Date: 10/09/2023
Date Signed: 10/09/2023 10:30:40 AM

Document Has Been Signed on 10/09/2023 10:30 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:JOYFUL CHAPTERFACILITY NUMBER:
415600832
ADMINISTRATOR:ROBERT WONGFACILITY TYPE:
740
ADDRESS:340 ALTA VISTA DRIVETELEPHONE:
(650) 827-5228
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 49CENSUS: 36DATE:
10/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Sharon WongTIME COMPLETED:
10:45 AM
NARRATIVE
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On 10/9/23, LPA Grace Donato conducted an unannounced visit to conduct a case management visit. LPA met with Administrator, Sharon Wong. LPA explained the purpose of the visit.

It was reported to Licensing that facility has not been reporting COVID-19 infection.

A resident (R1) who came from a Skilled Nursing Facility was transferred here on a Sunday. When R1 arrived at the facility there was no confirmation of any COVID-19 test, but was requested by the facility. R1 was already coughing when R1 arrived at the facility, so a test was done and turned out positive. R1 was sent to the hospital right away. R1 came back after 3 days still infected but isolated in the room. No incident report was submitted to Licensing.

Deficiency is cited today as the facility did not report said incident to Licensing.

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. Report was discussed and a copy of this report and the Appeal Rights are provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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 10/09/2023 10:30 AM - It Cannot Be Edited


Created By: Grace Donato On 10/09/2023 at 09:16 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: JOYFUL CHAPTER
FACILITY NUMBER: 415600832

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2023
Section Cited
CCR
87211(a)(D)

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87211Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(D) Any incident which threatens the welfare, safety or health of any resident, ... This requirement was not met as evidenced by:
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Licensee to submit a plan to address reporting reqiurements to Licensing. Licensee to submit by POC due date.
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Based on interview, there was no report submitted to Licensing regarding a COVID-19 infection which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Jackie Jin
LICENSING EVALUATOR NAME:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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