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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600895
Report Date: 08/17/2019
Date Signed: 08/17/2019 03:34:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:SENIORS AT CRANEFACILITY NUMBER:
415600895
ADMINISTRATOR:VIZCONDE, GIANNE PATRICEFACILITY TYPE:
740
ADDRESS:690 CRANE AVENUETELEPHONE:
(650) 274-0546
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY:6CENSUS: 6DATE:
08/17/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Gianne Vizconde, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Praveen Singh arrived unannounced to conduct a required annual inspection. LPA initially met with Assistant Administrator Rivina Timuat and then met with Gianne Vizconde arrived later during the inspection. LPA verified all staff present received criminal record clearances and were associated to the facility.

LPA toured facility inside and out, including but not limited to bedrooms, bathrooms, living room, kitchen, dining room, and outside area. LPA observed hot water temperature in a resident bathroom measured at 105.6 degrees F. LPA observed each room was provided with adequate lighting and furniture and hygiene supplies, toiletries, and extra linens were available. LPA observed bathrooms contained grab bars and non-skid mats. LPA toured the kitchen and observed a sufficient two (2) day supply of perishable and seven (7) day supply of non-perishable foods. At approximately 12:50 p.m., LPA observed scissors, and two knives in an unlocked kitchen drawer. LPA observed two locked medication cabinets in the kitchen for centrally stored medications and observed centrally stored medications were properly labeled and physician orders were maintained in the file.

LPA observed first aid kits and flashlights at the facility and observed that fire extinguishers were last serviced on 4/1/19. LPA reviewed staff and resident files. LPA observed an Emergency Disaster Plan binder was kept at the facility. At approximately 2:30 p.m., LPA observed emergency drill log indicated last drill was conducted on 3/8/19.

See LIC809-C for continued report

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2019
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: SENIORS AT CRANE
FACILITY NUMBER: 415600895
VISIT DATE: 08/17/2019
NARRATIVE
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The following forms need updating and submitted to LPA Singh via email by: 8/23/19

- LIC 309- Administrative Organization
- LIC 308- Designation of Administrative Responsibility
- LIC 500 - Personnel Report
- Proof of Liability Insurance
- LIC 610E - Emergency Disaster Plan

Deficiencies are cited per California Code of Regulations, Title 22, and begins on the next page. Failure to correct deficiencies may result in civil penalties.



Exit interview conducted and a copy of this report and Appeal Rights provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2019
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: SENIORS AT CRANE
FACILITY NUMBER: 415600895
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/17/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/17/2019
Section Cited
CCR
87705(f)(1)
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Care of Persons with Dementia. (f) The following shall be stored inaccessible to residents with dementia:

(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Administrator locked knives in a locked cabinet in LPA's presence.

Deficiency cleared during inspection
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This requiement is not met as evidenced by licensee's failure to lock kitchen knives.

LPA observed scissors and two knives in an unlocked kitchen drawer.
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Type B
08/23/2019
Section Cited
CCR
87705(i)(8)
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Care of Persons with Dementia. (8) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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Administrator states a fire and safety drill will be conducted and a copy of the drill log will be sent to LPA Singh via email by POC date.
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This requirement is not met as evidenced by licensee's failure to conduct fire drills every three months.

LPA observed that the facility safety drill log indicated last drill was conducted on 3/8/19.
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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.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Praveen SinghTELEPHONE: (510) 622-2625
LICENSING EVALUATOR SIGNATURE:

DATE: 08/17/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2019
LIC809 (FAS) - (06/04)
Page: 3 of 3