415600841-11-15-2023-14-AS-KHOS-CY8JZW-20231205063014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600841
Report Date: 11/15/2023
Date Signed: 11/15/2023 12:00:21 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/08/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231108103204

FACILITY NAME:	SAN BRUNO CARE HOME		FACILITY NUMBER:	415600841
ADMINISTRATOR:	FORONDA-CAYABYAB, MARIE J		FACILITY TYPE:	740
ADDRESS:	1382 WILLIAMS AVENUE		TELEPHONE:	(650) 827-1382
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 5	DATE:	11/15/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Caregivers, Ruben Cabrera and Jennie Pacay		TIME COMPLETED:	12:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Alteration to Existing Building
Fire Safety

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On November 15, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced complaint visit. LPA met with caregivers, Ruben Cabrera and Jennie Pacay and explained the purpose of the visit. The administrator, Marie Cayabyab arrived toward the end of the visit and met with LPA.

During today's visit, LPA toured the facility , interviewed administrator and facility staff.

During the tour, LPA observed a living space/loft in the garage and an Accessory Dwelling Unit (ADU) in the backyard. Both of these observations were not included in the facility sketch that was submitted to CCL. In addition, there were "yellow tags" on the doors of both these locations that was placed by the City Of San Mateo Code Enforcement on 11/8/2023 after they were determined to be inhabitable space.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 14-AS-20231108103204

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN BRUNO CARE HOME	FACILITY NUMBER: 415600841
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/16/2023 Section Cited CCR 87305(a)	1 2 3 4 5 6 7	87305 Alterations to Existing Building or New Facilities..(a) Prior to construction or alterations, all facilities shall obtain a building permit.	1 2 3 4 5 6 7	Licensee to submit a written plan in writing to address the garage attic and the ADU until proper building permit(s) is obtaining. Licensee will submit a copy of the written plan to CCL by 11/16/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility build a living space in the garage attic and a ADU in the backyard without obtaining a building permit which poses an immediate health risk for residents in care.	8 9 10 11 12 13 14
Type A 11/16/2023 Section Cited CCR 87203	1 2 3 4 5 6 7	87203 Fire Safety..All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.	1 2 3 4 5 6 7	Licensee to submit a written plan in writing to address how to provide habitable living accommodations for staff until proper fire clearance has been obtained. Licensee will submit a copy of the written plan to CCL by 11/16/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility staff members were occupying the ADU and the garage attic as living space prior to obtaining proper fire clearance which poses an immediate health risks to residents in care.	8 9 10 11 12 13 14

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20231108103204

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: SAN BRUNO CARE HOME	FACILITY NUMBER: 415600841
	VISIT DATE: 11/15/2023

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
26
27
28
29
30
31
32

According to staff #1 (S1), the loft in the garage attic was a living space for S1 and staff # (2) S2 and the Accessary Dwelling Unit (ADU) in the backyard was a living space for staff # 3(S3) who was an on-call staff, but when S3 was informed that he/she could no longer stay there about a couple weeks ago, he/she stop working at the facility.

According to S1 and staff # 4 (S4), they did not know when the garage attic and the ADU were build but they stated that the garage attic was used for isolation for staff who tested possible for COVID-19 during the pandemic.

According to the administrator, the garage attic and the ADU were intended to be used for staff isolation during the Pandemic and they continued to be used as such after the Pandemic.

In addition, the administrator stated they are in process of getting a building permit for the ADU.

Based on observations, and interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with the administrator. A copy is provided and Appeal Rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 3