415600855-11-21-2023-14-AS-CYAG-CXSVAJ-20231121151601

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600855
Report Date: 11/18/2023
Date Signed: 11/21/2023 03:16:10 PM

Document Has Been Signed on 11/21/2023 03:16 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:	ARAVILLE RESIDENTIAL CARE HOME II		FACILITY NUMBER:	415600855
ADMINISTRATOR:	PANIZA, DORIE		FACILITY TYPE:	740
ADDRESS:	1136 VERMONT AVENUE		TELEPHONE:	(650) 799-5722
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	11/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Rodrigo Mumanglag and Elma Dajao		TIME COMPLETED:	01:00 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	Unannounced annual visit made out to this facility on 11/18/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility live-in caregivers, Rodrigo Mumanglag and Elma Dajao, who were briefly interviewed at this time. This LPA requested that they go ahead and contact the facility designated Administrator, Dorie Paniza, to inform her that CCL was present at this time for an annual visit. She was unable to be present at today's annual visit but gave consent for her present caregivers to sign all documents at this time. Current census was 6 residents. There was one resident under the care of hospice at this time according to statements made by the facility caregivers. This facility does have an approved hospice waiver to be able to accept and retain up to (2) hospice residents at any given time. Tour of this facility was conducted. A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were observed to be locked and made inaccessible to the residents at this time. Cleaning agents, bleach, and other supplies were observed to be locked and made inaccessible to the residents at this time. A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times. Medication cabinet, located in the facility staff room, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility staff at this time. A review of the facility Medication Administration Record and dispensing log was conducted. Medication cabinet was observed to be locked and made inaccessible to the residents at this time. Living room, dining area, and all other areas intended for resident use were observed to furnished and maintained in compliance at this time and able to meet the needs of the residents. A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

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

LIC809 (FAS) - (06/04)

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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: ARAVILLE RESIDENTIAL CARE HOME II	FACILITY NUMBER: 415600855
	VISIT DATE: 11/18/2023

NARRATIVE

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and able to meet the needs of the residents at this time.
A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be presentand in good repair at this time.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry area, located in the garage, was observed to be unlocked but did not house any detergents, soaps, or bleach at this time. It was learned that all cleaning and laundry supplies were separately locked and made inaccessible to the residents at all times.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. Additional food storage units were observed to be present and in good repair at this time. Additional nonperishable food supplies were observed to be present along with emergency food supplies as well.
First aid kit, located in kitchen area, was observed to be present and contained all of the required components at this time.
Fire extinguisher was observed to be placed in the kitchen area at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
A review of (6) resident files was conducted and noted on the LIC 858.
A review of (4) resident staff files was conducted and noted on the LIC 859.

The following forms and documents were requested to be updated and submitted into CCL in order to update this facility file:

LIC 308
LIC 400
LIC 500
LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.
Appeal Rights were printed and a copy was given to the facility representative at this time. Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/21/2023 03:16 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II	FACILITY NUMBER: 415600855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(2)

Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the licensee did not comply with the section cited above in [1] out of [6] residents was deemed to be bedridden at this time but this facility does not have an approved bedridden fire clearance which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2023
	Plan of Correction
1 2 3 4	The facility representative stated that a bedridden fire clearance will be requested by this facility and an addendum to this facility's program will be completed and submitted into CCL for review by the assigned LPA. A statement of correction, along with all required forms and documents, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on the record review, the licensee did not comply with the section cited above in [1] out of [6] residents did not have a proper TB clearance on their medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2023
	Plan of Correction
1 2 3 4	The facility representative stated that an updated medical assessment will be completed for the resident to reflect proper TB clearance. A statement of correction, along with the updated medical assessment, will be completed and submitted into CCL by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/21/2023 03:16 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II	FACILITY NUMBER: 415600855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in [4] out of [6] residents did not have an updated annual appraisal performed to address any changes in residents' care and supervision needs which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2023
	Plan of Correction
1 2 3 4	The facility representative stated that re-appraisals will be requested by this facility unto the resident's attending physician and an updated assessment will be completed and submitted into CCL for review by the assigned LPA. A statement of correction, along with all required forms and documents, will be completed and submitted into CCL by the due date.

Type A

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above since there was not a sufficient supply of nonperishable food items to meet the required 7-day requirement at all times which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2023
	Plan of Correction
1 2 3 4	The facility representative stated that additional food items will be purchased in order to satisfy the required 7-day nonperishable food supply at all times. A statement of correction, along with proof of food purchase receipts, will be completed and submitted into CCL by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/21/2023 03:16 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ARAVILLE RESIDENTIAL CARE HOME II	FACILITY NUMBER: 415600855
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87628(a)

Diabetes

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in that a resident diagnosed with diabetes was unable to conduct their own glucose testing and insulin injections at this time and were solely reliant on the facility staff to perform them which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/19/2023
	Plan of Correction
1 2 3 4	The facility representative stated that a reappraisal of this diabetic resident will be conducted and this facility will be required to acquire the necessary health care needs in order to meet the continuing care needs of this resident. A statement of correction, along with all required forms and documents, will be completed and submitted into CCL by the due date.

Type A

Section Cited

CCR

87705(c)(5)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [6] residents did not have an updated annual medical assessment which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/25/2023
	Plan of Correction
1 2 3 4	The facility representative stated that an updated medical assessment will be completed and submitted into CCL for review by the assigned LPA. A statement of correction, along with the updated annual medical assessment, will be completed and submitted into CCL by the due date.

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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023

LIC809 (FAS) - (06/04)

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