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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 08/22/2025
Date Signed: 08/22/2025 01:18:17 PM

Document Has Been Signed on 08/22/2025 01:18 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: 6DATE:
08/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Bella TercianoTIME VISIT/
INSPECTION COMPLETED:
01:28 PM
NARRATIVE
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On August 22, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrators, Anthony Diaz and Bella Terciano and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are six resident rooms; all of which are private resident rooms. Resident rooms were observed to be clean with all required furniture. There is one staff room. Two full bathrooms were observed to be clean, odor-free and in good repair. Water temperature throughout the facility measured between 108-114 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete.

Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables, however did not observe seven day non-perishables. Medications and chemicals were observed locked an inaccessible to residents in care. Sharps were observed unlocked and accessible to residents. Sharps were immediately locked by caregiver.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of
July 2024. LPA reviewed 5 resident records and 5 staff records. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Charitra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2025
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 6
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/22/2025 01:18 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/22/2025 at 12:29 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: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed sharps to be unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2025
Plan of Correction
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Deficiency cleared and corrected. Sharps were immediately locked by caregiver.
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff records reviewed, 5/5 staff were observed to not have the required training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2025
Plan of Correction
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Licensee/administrator shall develop a plan in writing on how to ensure staff complete annual training. The plan shall include conducting audits and ensuring all training is logged and maintained in each staff file.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 08/22/2025 01:18 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/22/2025 at 12:29 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: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record reviewed, facility did not have any documentation of the emergency drills being conducted quarterly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2025
Plan of Correction
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The licensee will develop a signed and dated plan to CCL by 8/23/2025 indicating when an emergency drill will be completed. The plan shall include ensuring that drills are conducted quarterly. The administrator will provide a copy of the emergency drill in-service sign in record to CCL by 8/26/2024.
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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 08/22/2025 01:18 PM - It Cannot Be Edited


Created By: Komal Charitra On 08/22/2025 at 12:29 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: 08/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, LPA did not observe 7 day non-perishables which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee/administrator will send LPA a photo of receipt and/or a photo of the non-perishables purchased.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident records reviewed, the licensee did not comply with the section cited above as 5/5 residents did not have documentation of resident reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/29/2025
Plan of Correction
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Licensee/administrator shall complete reappraisals for all 6 residents and provide LPA a plan on how to ensure reappraisals are being updated every 12 months or as needed.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2025


LIC809 (FAS) - (06/04)
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