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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600925
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:41:11 PM

Document Has Been Signed on 01/25/2024 12:41 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:CALIFORNIA ASSISTED DEVELOPMENT LLCFACILITY NUMBER:
415600925
ADMINISTRATOR:LOCHIN, STACYFACILITY TYPE:
775
ADDRESS:3641 HAVEN AVENUE, STE ATELEPHONE:
(415) 573-7031
CITY:MENLO PARKSTATE: CAZIP CODE:
94025
CAPACITY: 40CENSUS: 14DATE:
01/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH: Program Director, Stacy LochinTIME COMPLETED:
01:00 PM
NARRATIVE
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On January 25, 2024, , Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Assistant Program Director, Dabatha Sequeira and explained the purpose of the visit. Program Director, Stacy Lochin joined the visit shortly thereafter.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. The day program has two floors; 4 activity/classroom areas, main activity room, kitchen, and bathrooms located on first floor and a computer lab and conference area located on the second floor. According to the Assistant Program Director, clients don't go on the second floor unless they are with staff using the computers. Activity rooms were observed to be clean, clear from tripping hazards, and spacious. During the visit, LPA observed clients doing activities in the main area and sufficient staff to provide care and supervision. LPA observed two separate bathrooms for women and men. Bathrooms were clean and odor-free; equipped with liquid soap and paper towels. Hot water temperature throughout the facility measured at 113 degrees F. Overall facility maintained a comfortable temperature and had sufficient lighting.

Kitchen door was observed the be locked. According to the Assistant Program Director, clients bring their lunches to the day program. Clients are able to store their lunches in the refrigerator. Medication, sharps, toxins, and chemicals were observed to be locked and inaccessible to clients. Kitchen was observed to be clean and free from pests and flies.

LPA checked all fire extinguishers which were inspected on 11/2023. First aid kit was observed to be present. Carbon monoxide detectors were not observed to be installed, however smoke alarms were present. LPA reviewed facilities emergency/ disaster plan. The last disaster drill was conducted on 12/2023. (continue to 809C)
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2024
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CALIFORNIA ASSISTED DEVELOPMENT LLC
FACILITY NUMBER: 415600925
VISIT DATE: 01/25/2024
NARRATIVE
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 LPA reviewed 5 client files and 5 staff files. Based on records reviewed; all staff files were current, however 4/5 client files reviewed did not have signed admission agreements, 3/5 client files did not have physician's report/ medical assessments, and 3/5 client files observed did not have updated Individualized Program Plans (IPPs).

Deficiencies of the California Code of Regulations, Title 22, are observed and cited on 809D.

Report is reviewed with Program Director, Stacy Lochin and a copy is provided with appeal rights.

SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2024 12:41 PM - It Cannot Be Edited


Created By: Komal Charitra On 01/25/2024 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CALIFORNIA ASSISTED DEVELOPMENT LLC
FACILITY NUMBER: 415600925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA did not observed carbon monoxide detectors in the building. According to the Program Director, the detectors have been purchased and needs to be installs. Nevertheless, the facility failed to ensure carbon monoxide detectors were installed at the building which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Program Director to ensure carbon monixide detectors are installed and in good working condition. Program Director to provide LPA a photo of installed detectors by 1/26/2024.
Type A
Section Cited
CCR
82069(a)(1)
Client Medical Assessments
(a) Prior to or within 30 calendar days following the acceptance of a client, the licensee shall obtain a written medical assessment of the client that determines the licensee's ability to provide necessary health-related services to the client. The assessment shall be used in developing the Needs and Services Plan. (1) The assessment shall be performed by a licensed physician or designee, who is also a licensed professional, and the assessment shall not be more than one year old when obtained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on clients file reviewed, LPA observed 3/5 client files without medical assessments / physician's orders which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/26/2024
Plan of Correction
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Program Director to submit a plan in writing to CCL to ensure all client files have (updated) medical assessments. This plan shall include how the facility will try to obtain a copy from client's responsible parties.
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
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 01/25/2024 12:41 PM - It Cannot Be Edited


Created By: Komal Charitra On 01/25/2024 at 12:13 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CALIFORNIA ASSISTED DEVELOPMENT LLC
FACILITY NUMBER: 415600925

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82068(a)
Admission Agreements
(a) The licensee shall complete and maintain an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 4/5 client files reviewed, LPA did not observe signed admission agreements from clients or clients' responsible parties which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Program Director to submit a plan in writing to CCL on how the facility will ensure all client files have signed admission agreements.
Type B
Section Cited
CCR
82068.2(d)(1)
Needs and Services Plan
(d) If the client has an existing needs appraisal or individual program plan (IPP) completed by a placement agency, or a consultant for the placement agency, the Department may consider the plan to meet the requirements of this section provided that: (1) The needs appraisal or IPP is not more than one year old.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on 3/5 client files reviewed, LPA did not observe updated IPPs which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2024
Plan of Correction
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Program Director to submit a plan in writing to CCL on how the facility will ensure all client files have updated IPPs. This plan shall include reaching out to GGRC and having a plan to routinely check to ensure IPPs are updated yearly for all clients.
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
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2024


LIC809 (FAS) - (06/04)
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