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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600871
Report Date: 02/20/2024
Date Signed: 02/20/2024 07:50:40 PM


Document Has Been Signed on 02/20/2024 07:50 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:PACIFIC CARE HOMEFACILITY NUMBER:
415600871
ADMINISTRATOR:JISON, RAFAEL A.FACILITY TYPE:
740
ADDRESS:3647 PACIFIC BLVDTELEPHONE:
(650) 345-1796
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 6DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Moddie AndayaTIME COMPLETED:
02:30 PM
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LPA Audrey Jeung toured facility and grounds. Six residents are accommodated in private rooms with private bathrooms. There are 2 staff rooms--one with 1 bed and the other has 2 beds. Fenced backyard is level, landscaped, and partially paved; it is shared with Pacific Care Home II (3653 Pacific Blvd.)--also operated by J & I LLC. There are no accessible bodies of water or fire safety hazards observed. Carbon monoxide detector is tested and operable. Medications and sharps are stored appropriately and inaccessible to clients, a comfortable room temperature is maintained, and lighting is sufficient for safety. First-aid kit is complete and maintained. Client files are reviewed, and medications are recorded on Centrally Stored Medications Records. A Disaster and Mass Casualty Plan is posted. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, as well as staff training records. Rafael Jison (RCFE x 3/24) and Moddie Andaya are certified RCFE administrators that oversee facility operations, with assistance from Wilhelm Ick (x 3/24).

As per legislation, effective 1/1/2015, the following information is posted: 1) text of Health and Safety Code 1569.269 AND CCR Title 22 Section 87468 (Personal Rights form LIC613C), per AB2171; 2) CCLD Hotline information, per SB895.

Signature page of Emergency Disaster Plan (LIC610) & proof of current liability insurance are given to LPA.

The following licensing forms are requested to be updated and submitted to CCLD by 3/5/24.

- Personnel Report (LIC500) is given to LPA.
- Administrative Organization (LIC309)
- Designation of Facility Responsibility (LIC308)

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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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Document Has Been Signed on 02/20/2024 07:50 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: PACIFIC CARE HOME
FACILITY NUMBER: 415600871

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff training records review, the licensee did not comply with the section cited above in 4 out of 5 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
There is no evidence that staff 1, 2, 3, 4 have received required annual training on postural supports and restricted health conditions
POC Due Date: 03/05/2024
Plan of Correction
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Proof that staff have received required 4 hours of annual training on hospice care, postural supports and restricted health conditions will be sent to CCLD BY DUE DATE
Type B
Section Cited
CCR
87705(c)(5)
CARE OF PERSONS WITH DEMENTIA
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
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Based on client records review, the licensee did not comply with the section cited above, as 2 out of 4 clients diagnosed with dementia do not have current medical assessment and/or appraisal on file, which poses a potential health, safety or personal rights risk to persons in care.
Client #1 has appraisal dated 11/21 and client #6 has appraisal dated 9/20 and MD report dated 8/20.
POC Due Date: 03/05/2024
Plan of Correction
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Updated MD report and/or appraisals for clients #1 and #6 to be sent to CCLD BY 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
LIC809 (FAS) - (06/04)
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