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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600848
Report Date: 09/12/2023
Date Signed: 09/12/2023 02:31:46 PM

Document Has Been Signed on 09/12/2023 02:31 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:
09/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Licensee Anthony and Sheila DiazTIME COMPLETED:
02:30 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 September 12, 2023 at 1:15 p.m, San Bruno Regional Office conducted an office meeting with Licensee, Anthony and Sheila Diaz to discuss the findings from an audit that was completed by CCL Audit Section.

Present in the meeting was Regional Manager, Vivien Helbling, Licensing Program Manager, Jackie Jin, Licensing Program Analyst, Murial Han and Auditor, Jacqueline Juarez joined virtually.
 
The Department has requested an audit to be completed by the CCL Audit Section to ensure that the facility has sufficient funds to continue operations as the sister facility that was operated by the same owner was closed due to non-payment of rent.

Based on the audit result, the licensee does not have a sound financial plan, has negative equity and is not generating enough income to meet its expenses. Licensee to ensure their corporate statues is reinstated and obligation with Franchise Tax Board (FTB) are paid. Licensee should work to reduce payroll cost, as payroll is absorbing all
income earned. With paying savings, Licensee to increase food expenses and become current with all utilities.

During today's meeting, the following findings and the violations were reviewed with the licensee: finding #1 Finances, the audit revealed that the Licensee is not making sufficient income to meet operating expenses; finding #2 Accountability of Licensing Governing Body, the audit revealed that the licensee did not pay operational expenses timely; finding #3, General Food Service Required, the audit revealed that the facility did not spend sufficient funds on food for 5 residents based on the USDA guidelines for male and female ages 51-70 and 71+; finding #4, Administrator Qualification, the audit revealed that the administrator did not ensure operating expenses were paid on time, and residents were supplied with sufficient food according to the USDA guidelines.





SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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 4
Document Has Been Signed on 09/12/2023 02:31 PM - It Cannot Be Edited


Created By: Murial Han On 09/08/2023 at 12:06 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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
87205(a)(b)

1
2
3
4
5
6
7
87205 Accountability of Licensee Governing Body..a) The licensee, whether an individual or other entity, shall exercise general supervision over the affairs of the licensed facility..(b) If the licensee is a corporation or an association, the governing body shall be
1
2
3
4
5
6
7
Licensee and administrator will develop a plan to ensure facility operation expenses including but not limiting to utility bills and rent are paid on time. Licensee will submit a copy of the plan to CCL by 9/13/2023. In addition, Licensee is to furnish proof that
obligations owed to FTB have been cleared and that corporate
8
9
10
11
12
13
14
active, and functioning in order to assure accountability.. This requirement is not met as evidenced by based on the audit result, the licensee failed to pay rent, utility bills on time and licensee's corporation status with Secretary of State is Franchise Tas Board (FTB) suspended which poses an immediately risk for residents in care.
8
9
10
11
12
13
14
status has been reinstated. If licensee is operating under a different corporation, a new license application must be submitted. Furthermore, facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide requested documents.
Type A
09/13/2023
Section Cited
CCR87555(a)

1
2
3
4
5
6
7
87555 General Food Service Requirements..a)The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary
1
2
3
4
5
6
7
The licensee and administrator will develop a plan to ensure facility is supplying food to all the residents in care according to the recommended dietary allowances. Licensee will submit a copy of the
8
9
10
11
12
13
14
Allowances of the Food and Nutrition Board of the National Research Council.. This requirement is not met as evidenced by based on the audit result, the facility failed to supplied food to resident to meet the nutritional guidelines which poses an immediately health risk to residents in care.
8
9
10
11
12
13
14
plan to CCL by 9/13/2023.
In addition, the facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide monthly food receipts.
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
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/12/2023 02:31 PM - It Cannot Be Edited


Created By: Murial Han On 09/08/2023 at 12:47 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: 09/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/13/2023
Section Cited
CCR
87213

1
2
3
4
5
6
7
87213 Finances..The licensee shall have a financial plan that conforms to the requirements of Section 87155, Application for License, and that assures sufficient resources to meet operating costs for care of residents;
1
2
3
4
5
6
7
The licensee will review facility financial status and make adjustments to ensure operating expenses are met. After the review, the licensee will develop a plan to ensure facility income is sufficient to cover all the operating expenses.
8
9
10
11
12
13
14
This requirement is not met as evidenced by based on the audit result, licensee is not making sufficient income to meet operating expenses which poses an immediately health risk to residents in care.
8
9
10
11
12
13
14
 A copy of such plan will be submitted to CCL by 9/13/2023.
In addition, the facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide requested documents.
Type A
09/13/2023
Section Cited
CCR87405(d)(1)(2)

1
2
3
4
5
6
7
87405 Administrator - Qualifications and Duties..(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply..(1) Knowledge of the requirements for providing care and supervision..
1
2
3
4
5
6
7
The licensee and administrator will review the regulation and provide a copy of a signed statement acknowledging the review. The administrator will provide a plan on how he/she will monitor to ensure residents are receiving food
8
9
10
11
12
13
14
(2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by the administrator failed to ensure residents are adequately fed and bills are paid in a timely manner which poses an immediately health risk to residents in care.
8
9
10
11
12
13
14
according to the Recommended Dietary Allowances, facility rent, and ancillary bills are paid in a timely fashion. The plan and the statement will be submitted to CCL by 9/13/2023. In addition, the facility will comply with Audit Section quarterly Financial Monitoring for a period of one year and provide request documents
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
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
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
VISIT DATE: 09/12/2023
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
Based on the audit findings and to ensure facility will be in compliance with Title 22 regulation, facility will comply with quarterly Financial Monitoring for a period of one year or until it is evident that the licensee has an adequate financial plan in place. The first due date being October 31, 2023 (July, August, and September 2023) documents are to include LIC 401, for the month of September 2023; bank statements for July- September 2023; utility bills, cable/phone bills and food receipts for the month of September 2023.

Deficiency is cited for the above violations on LIC 809D.

This report is reviewed and discussed with the licensee.

A copy this report and appeal rights are provided.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4