415600855-7-18-2024-14-AS-MHAN-D79PQD-20240717113059

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600855
Report Date: 07/17/2024
Date Signed: 07/18/2024 08:46:04 AM

Document Has Been Signed on 07/18/2024 08:46 AM - 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: 4	DATE:	07/17/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Mila De Villa		TIME COMPLETED:	11:40 AM

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 July 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. Upon arrival, LPA met with caregiver, Mila De Villa and explained the purpose of today's visit. The administrator and the assistant administrator arrived shortly thereafter and assisted with the inspection. Current census is 4 residents. A tour of the facility was conducted with caregiver. This is a single story facility with 6 bed rooms (2 staff rooms, 2 private rooms and 2 shared rooms). Living room, dining area, kitchen and all other areas intended for resident use were observed to be furnished and able to meet the needs of the residents. The indoor and outdoor passageways were free of obstruction. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

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: 07/17/2024

NARRATIVE

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Hot water temperature in the bathroom and kitchen were measured at 105- 115 degrees Fahrenheit. Fire extinguisher was checked.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.

LPA requested for a copy of the Liability Insurance, control of property, and administrator certification to be submitted by 7/18/2024.

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. .

This report is reviewed and discussed with the administrator and the assistant administrator. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2024 08:46 AM - 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: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)(1)

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: (1) Nonambulatory persons. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above based on the LIC 602, 4 out of 4 residents are non-ambulatory and the facility is approved for 2 non-ambulatory residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	The administrator and the assistant administrator will contact the physicians and obtain an updated LIC 602 for both residents. If the status of both residents remain as non-ambulatory, the facility will work with CCL to obtain fire clearance. The facility will provide either an updated physician order for both residents or a plan of correction to CCL by 7/18/2024.

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
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility was not able to provide documents to proof that emergency drills were conducted after Oct 31, 2023 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	The administrator and the assistant administrator will develop a plan to ensure compliance and will submit a copy of the plan to CCL by 7/18/2024.

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	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2024 08:46 AM - 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: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 3 out of 4 residents observed to have half bed rails without a physician's order which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/18/2024
	Plan of Correction
1 2 3 4	The administrator and the assistant administrator will provide a plan/physician order to ensure compliance and submit a copy of the plan to CCL by 7/18/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/18/2024 08:46 AM - 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: 07/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(5)

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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 resident with diagnosis dementia did not have an updated medical assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/24/2024
	Plan of Correction
1 2 3 4	The administrator and the assistant administrator will provide a plan to ensure compliance and submit a copy of the plan to CCL by 7/24/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2024

LIC809 (FAS) - (06/04)

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