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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600833
Report Date:
04/24/2023
Date Signed:
04/24/2023 05:31:05 PM
Document Has Been Signed on
04/24/2023 05:31 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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
ADMINISTRATOR:
DEBORAH M. DAHLEN
FACILITY TYPE:
740
ADDRESS:
2585 ARDEE LANE
TELEPHONE:
(650) 873-8635
CITY:
SOUTH SAN FRANCISCO
STATE:
CA
ZIP CODE:
94080
CAPACITY:
6
CENSUS:
3
DATE:
04/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
11:25 AM
MET WITH:
Deborah Dahlen
TIME COMPLETED:
05:45 PM
NARRATIVE
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LPA Grace Donato & LPM Jackie Jin conducted an unannounced annual visit to the facility. LPA & LPM met with the administrator Deborah Dahlen.
LPA & LPM toured the facility inside and outside with the administrator. While touring the facility it was observed that the temperature was af 78 deg F. Hot water was also tested and temperature was 110 deg F.Each resident rooms were checked. The residents have adequate amount of linens and incontinence care items. All personal belongings are intact. All residents are comfortable and taken care of. Carbon monoxide monitor is working properly. All fire extinguishers have been checked. Bathrooms were observed to be in good repair equipped with non-skid mats and grab bars. There is also adequate amount of food. 2 days for perishables and & 7 days non-perishable.
Medication review was done and all medications are accounted for and centrally stored medication records are updated.
One staff record was reviewed. All staff has criminal record clearance and are associated with the facility. Based on record reviews, it was noted that the facility does not have updated CPR & First Aid training. Personnel records are not maintained resulting for some documents being unavailable when needed.
Resident records are checked and all are complete and updated. One out of one resident is in hospice and it was observed that the Hospice agreement was not in the file.
Outside the facility, there were several sharps found around the garden area, the administrator corrected the deficiency by storing them on a locked shed.
SUPERVISOR'S NAME:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
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11
Document Has Been Signed on
04/24/2023 05:31 PM
- It Cannot Be Edited
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons does not have certificates for CPR and first aid which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/25/2023
Plan of Correction
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Licensee shall develop a plan to ensure that 3 out of 3 staff will receive training for CPR & First Aid by POC due date. Licensee shall submit training certificates to CCLD by 5 business days, 04/28/2023.
Type A
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 personnel records were not available upon inspection which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/25/2023
Plan of Correction
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Licensee shall submit a plan to explain how facility will have personnel records available when CCLD requests the files by POC due date.
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
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
2
of
11
Document Has Been Signed on
04/24/2023 05:31 PM
- It Cannot Be Edited
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 personnel files were not maintained in the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/25/2023
Plan of Correction
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Licensee shall provide a plan on how the facility will be able to maintain personnel records that would be readily available if CCLD requests for it by POC due date.
Section Cited
Personnel Records
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
3
of
11
Document Has Been Signed on
04/24/2023 05:31 PM
- It Cannot Be Edited
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 3 persons does not have certificates for First Aid which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
04/25/2023
Plan of Correction
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Licensee shall develop a plan to ensure that 3 out of 3 staff will receive training for First Aid by POC due date. Licensee shall submit training certificates to CCLD by 5 business days, 04/28/2023.
Section Cited
Deficient Practice Statement
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3
4
POC Due Date:
Plan of Correction
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2
3
4
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
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
4
of
11
Document Has Been Signed on
04/24/2023 05:31 PM
- It Cannot Be Edited
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/24/2023
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
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out o 4 staff did have health screening and TB test results which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/25/2023
Plan of Correction
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2
3
4
Licensee shall develop a plan to provide the files to CCLD by POC due date.
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
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
5
of
11
Document Has Been Signed on
04/24/2023 05:31 PM
- It Cannot Be Edited
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(6)
Personnel Requirements - General
(6) The licensee shall maintain documentation pertaining to staff training in the personnel records, as specified in Section 87412(c)(2). For on-the-job training, documentation shall consist of a statement or notation, made by the trainer, of the content covered in the training. Each item of documentation shall include a notation that indicates which of the criteria of Section 87411(c)(3) is met by the trainer.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 staff did not have documentations of training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
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3
4
Licensee shall submit the training documentations to CCLD by POC due date.
Type B
Section Cited
CCR
87633(h)(1)
Hospice Care for Terminally Ill Residents
(h) For each terminally ill resident receiving hospice services in the facility, the licensee shall maintain the following in the resident's record: (1) A written request for acceptance or admittance to or retention in the facility while receiving hospice services, along with any advance directive and/or request regarding resuscitative measures form executed by the resident or (in certain instances) the resident's Health Care Surrogate Decision Maker.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 1out of 1 resident do not have Hospice agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
1
2
3
4
Licensee shall submit a copy of the Hospice agreement to CCLD by POC due date.
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
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
6
of
11
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
VISIT DATE:
04/24/2023
NARRATIVE
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While touring around the facility, it was observed in the bathroom that chemicals were unlocked cabinet. Administrator cleared the deficiency by installing a lock for the cabinet. It was also observed that there were several chemicals in the garage. Deficiency was cleared by fixing the lock for the garage door so it won't be accessible to the residents.
Facility doesn't have a record of Emergency Disaster drill log. LPA & LPM advised administrator that drill shall be completed quarterly.
LPA requested licensee to submit the following by 4/28/2023:
LIC 308 Designation of Facility Responsibility
LIC 610D Emergency Disaster Plan
LIC 500 Personnel Report
Updated Administrator Certificate
Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.
Report is reviewed with Co-Administrator and a copy is provided with appeal rights.
SUPERVISOR'S NAME:
Jackie Jin
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
10
of
11
Document Has Been Signed on
04/24/2023 05:31 PM
- It Cannot Be Edited
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:
1ST PACIFIC COAST HOMES II
FACILITY NUMBER:
415600833
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
04/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates:
(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above by not being able to provide an Emergency Disaster drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
04/28/2023
Plan of Correction
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2
3
4
Licensee shall conduct an emergency disaster drill and submit to CCLD the emergency disaster log showing the drill uis completed and to submit a plan on when quarterly drills are to be held.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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
TELEPHONE:
(714) 319-3786
LICENSING EVALUATOR NAME:
Grace Donato
TELEPHONE:
(714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE:
04/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/24/2023
LIC809
(FAS) - (06/04)
Page:
11
of
11