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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 02/14/2023
Date Signed: 02/14/2023 02:43:02 PM


Document Has Been Signed on 02/14/2023 02:43 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:WESTBOROUGH MANOR 6FACILITY NUMBER:
415600848
ADMINISTRATOR:TERCIANO, BELLAFACILITY TYPE:
740
ADDRESS:2550 CATALPA WAYTELEPHONE:
(650) 875-9016
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 6DATE:
02/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Bella TercianoTIME COMPLETED:
11:45 AM
NARRATIVE
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On 2/14/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed no COVID-19 signs posted by the front entrance. LPA was greeted and screened at the front entrance by caregiver, Marcelina Bamba and LPA explained the purpose of the visit. Caregiver called and informed administrator of this visit and administrator arrived shortly thereafter to assist with the inspection.

LPA toured facility and grounds and LPA did not observed any infection control and COVID-19 signs through out the facility, No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies. there are 6 residents at the facility and all of them are in a private room. PPE supply and the environmental cleaning supply are adequate, bathrooms are equipped with liquid soap and paper towels, hand washing instruction is not observed by the hand washing stations.

Medications, and sharps are stored appropriately and inaccessible to resident. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and food supply was checked and observed to be sufficient. First-aid kit is inspected and complete.

During the tour of the facility, LPA observed toxins and chemicals are stored in a closet but the door was not lock. The administrator attempted to lock the door but was not successful as there was a blue tape covering the lock which prevented the door from locking.

Based on observation, and record review, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D as the disinfectants and chemicals were not inaccessible to residents and there was no infection control/COVID-19 signs observed. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator and licensee. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 02/14/2023 02:43 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: WESTBOROUGH MANOR 6
FACILITY NUMBER: 415600848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above- during the facility tour that was provided by the administrator, LPA observed chemical and toxins are stored in a closet, however, door was not locked as there was a blue tape covering the lock that prevented the door from locking which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/15/2023
Plan of Correction
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The administrator removed the tape and the door was locked. The administrator will provided in-services to staff on the importance of locking the chemical/toxins storage closet door at all times. In addition, the administrator will develop a plan to ensure compliance. The administrator will provide a copy of the plan and a copy of the staff in-service sign-in record to CCL by 2/15/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/14/2023 02:43 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: WESTBOROUGH MANOR 6
FACILITY NUMBER: 415600848

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above in as LPA did not observe any COVID-19/Infection control postings by the front entrance and in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2023
Plan of Correction
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The administrator will post the signs by the front entrance, in the bathrooms and within the facility. The administrator will send pictures of the postings by 2/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3