<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 11/06/2024
Date Signed: 11/06/2024 04:35:21 PM

Document Has Been Signed on 11/06/2024 04:35 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:WESTBOROUGH MANOR 6FACILITY NUMBER:
415600848
ADMINISTRATOR/
DIRECTOR:		TERCIANO, BELLAFACILITY TYPE:
740
ADDRESS:2550 CATALPA WAYTELEPHONE:
(650) 875-9016
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 6CENSUS: 5DATE:
11/06/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:40 AM
MET WITH:Caregiver, Linda MondejarTIME VISIT/
INSPECTION COMPLETED:
01:10 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
On November 6, 2024, Licensing Program Analyst (LPA), Murial Han conducted an case management visit to follow up on a case management visit on 10/23/2024.
LPA met with caregiver, Linda Mondejar who called the administrator/licensee Anthony Diaz and explained the purpose of today's visit.

During the case management visit on 10/23/2024, LPA issued a deficiency under Health and Safety Code 1569.605 as the facility did not have a copy of the current Liability Insurance and the plan of correction was due on 10/25/2024.

On 10/28/2024 at 10:54am, the facility Licensees submitted a copy of a one page Worker’s Compensation and Employer’s Liability Insurance from the Berkshire Hathaway Guard Insurance Companies and initially LPA observed the facility was not listed under named insured. LPA informed the Licensees of the observation, and a few hours later at 1:16PM, the Licensee submitted an addendum of 2 more pages including the name insured- Westborough Manor on the 2nd page and facility's address on the 3rd page.

After viewing the insurance policy, LPA proceed with calling the insurance company and the insurance retailer (Board Spectrum Insurance) for verification and they confirmed that this policy was for Worker's Compensation and it did not cover for General Liability Insurance and that the policy was terminated in 2018-2019 due to non-payment. In addition, they stated that when the policy was active, it did not include this facility and they did not know how the facility’s address appeared on policy.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 04:35 PM - It Cannot Be Edited


Created By: Murial Han On 11/06/2024 at 12:02 PM
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: WESTBOROUGH MANOR 6
FACILITY NUMBER: 415600848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2024
Section Cited
CCR
87207

1
2
3
4
5
6
7
87207 False Claims ..No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
1
2
3
4
5
6
7
The administrator/licensee will develop a plan in writing and the plan shall indicate that the administrator/licensees has reviewed this regulation and what the administrator/licensees will do to prevent this from happening again.
8
9
10
11
12
13
14
This requirement is not met as evicenced by based on interviews, observation and record review, the administrator/licensee provided an insurance policy that was terminated in 2018-2019 and when it was active, it did not insure this facility which poses an immediate health risks to residents in care.
8
9
10
11
12
13
14
The administrator/licensees will provide a copy of the plan to CCL by 11/7/2024.
Type A
11/07/2024
Section Cited
CCR87405(d)(2)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications..(2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
1
2
3
4
5
6
7
The administrator/Licensees will develop a plan in writing and the plan shall indicate that the administrator/licensees have reviewed the Regulation and the plan to ensure the facility is in compliance with the Regulations, and laws including but not limiting
8
9
10
11
12
13
14
This requirment is not met as evidenced by based on observation, record review and interview, the administrator did not ensure the facility has an active General Liability Insurance Policy which poses an immediate health and safety risks to residents in care.
8
9
10
11
12
13
14
on obtaining a current General Liability Insurance for the facility.

The administrator/Licensees will provide a copy of the plan to CCL by 11/7/2024.
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 Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
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: WESTBOROUGH MANOR 6
FACILITY NUMBER: 415600848
VISIT DATE: 11/06/2024
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
Based on observation and record review, the administrator/licensees provided a copy of the expired worker’s compensation insurance policy and not the general liability insurance and the policy was altered as the insurance company confirmed that this facility was not included on the policy yet it appeared on the policy that was provided by the licensees. In addition, the administrator did not conform to the laws, rules, and regulations as the administrator did not ensure the facility has an active Liability Insurance Policy.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the caregiver and administrator/licensee over the phone.

A copy of this report and the Appeal Rights are provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3