415600895-4-18-2024-14-AS-MHAN-D4FQRV-20240418122436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600895
Report Date: 04/18/2024
Date Signed: 04/18/2024 06:24:08 PM

Document Has Been Signed on 04/18/2024 06:24 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:	SENIORS AT CRANE		FACILITY NUMBER:	415600895
ADMINISTRATOR:	VIZCONDE, GIANNE PATRICE		FACILITY TYPE:	740
ADDRESS:	690 CRANE AVENUE		TELEPHONE:	(650) 274-0546
CITY:	FOSTER CITY	STATE: CA	ZIP CODE:	94404
CAPACITY:	6	CENSUS: 5	DATE:	04/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Caregiver, Jannette Sumampong		TIME COMPLETED:	12:35 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 April 18, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Jannette Sumampong. LPA explained the purpose of the visit. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed 5 resident rooms (5 private rooms) and 1 staff room. Rooms were spacious and included all required furnishings. Bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Hot water temperature in the kitchen, and bathroom was measured at 106- 111 degrees F. 2 days for perishables and & 7 days non-perishable were observed to be present. During the tour of the garage, LPA observed the garage was sectioned off in the middle; one side is for laundry, toxins and chemical storage, etc. and the other side consisted of: a folding bed, clothing, a laundry basket with clothes inside, toiletries, portable storage units, a personal check, a wallet, etc. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire drill records were reviewed. A review of (3) facility resident records was conducted. A review of (3) facility staff records was conducted.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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 04/18/2024 06:24 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: SENIORS AT CRANE	FACILITY NUMBER: 415600895
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87305(a)

This requirement is not met as evidenced by: 87305 Alterations to Existing Building or New Facilities
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed living furniture and supplies in the garage which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	The administrator will remove the items in the garage by 4/19/2024 and will provide photos to CCL. The administrator will develop a plan to ensure compliance and if the facility decides to convert half of the garage into a living space for staff, then in the plan, the administrator will indicate it and include the process of working on the permit with the city. The administrator/licensee will provide a copy of the dated and signed plan to CCL by 4/19/2024.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SENIORS AT CRANE	FACILITY NUMBER: 415600895
	VISIT DATE: 04/18/2024

NARRATIVE

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During today's inspection, there were 3 residents and 3 staff present.

LPA requested these documents to be submitted by 4/22/2024: control of property, and liability insurance.

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 caregiver. A copy is provided and the appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024

LIC809 (FAS) - (06/04)

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