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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600835
Report Date: 10/10/2024
Date Signed: 10/10/2024 06:50:18 PM


Document Has Been Signed on 10/10/2024 06:50 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:AGEWAY BOARDING CARE #2FACILITY NUMBER:
415600835
ADMINISTRATOR:DAYEH, ANAFACILITY TYPE:
740
ADDRESS:1325 ROYAL AVENUETELEPHONE:
(650) 315-2621
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 5DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Grace Tolentino & Mihael DayehTIME COMPLETED:
07:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds--including detached storage shed--for this 6 bed RCFE, consisting of 5 client bedrooms, full bathroom, 5 half bathrooms, shower room, kitchen, living and dining rooms, and recreation room. There are no accessible bodies of water or fire safety hazards observed. Hot water temperature is tested at 112 degrees in full bathroom. Food supply, signal system, and first-aid kit are inspected, and hygiene items for general use are maintained. Client files are reviewed, An Emergency Disaster Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Staff records and medications will be reviewed at a later date, due to time constraints. Ana Dayeh, Mihael Dayeh (x11/24), and Grace Tolentino are certified RCFE administrators that oversee facility operations. There are 2 clients receiving hospice services.

The following forms are requested to be completed and returned to CCL by 10/17/24:

• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• Facility Sketch (including dimensions)
• Proof of control of property
• LIC 610E Emergency Disaster Plan (9 pages, with signed and dated page 9)
• LIC 9282 Infection Control Plan (page 5 signed and dated)



Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. See also Technical Advisory Notes--2 pages.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
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 3


Document Has Been Signed on 10/10/2024 06:50 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: AGEWAY BOARDING CARE #2
FACILITY NUMBER: 415600835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/11/2024
Section Cited
CCR
87608(a)(5)(B)

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POSTURAL SUPPORTS
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met, as client #4 has full bed rails, and there is no
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Full bed rails for client #4 must be removed unless the hospice care plan is maintained and includes full bed rails.
Plan/proof of correction to be faxed to CCLD BY DUE DATE.
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hospice care plan. Licensee failed to ensure that hospice care plan is maintained and includes full bed rails, which poses an immediate health, safety or personal rights risk to clients in care.
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Type B
10/17/2024
Section Cited
CCR87633(b)

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HOSPICE CARE OF TERMINALLY ILL
A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include specific information. This requirement is not met, as hospice care plans for 2 out of 2 residents receiving hospice care are not maintained.
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Hospice care plans for clients #3 and #4 will be sent to CCLD BY DUE DATE.
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This poses a potential health, safety or personal rights risk to clients in care.
Clients #3 and #4 are receiving hospice services, but hospice care plans are not maintained.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/10/2024 06:50 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: AGEWAY BOARDING CARE #2
FACILITY NUMBER: 415600835

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
87705(c)(5)

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CARE OF PERSONS WITH DEMENTIA
Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This requirement is not met, as appraisals or
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Appraisals for clients #2 and #3 will be updated, signed and dated, and copies sent to CCLD BY DUE DATE.
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Needs and Services Plans for 2 out of 5 clients are not current, which poses a potential health, safety or personal rights risk to clients in care.
Clients #2 and #3 are diagnosed with dementia, but reappraisals are dated more than 12 months ago.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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