415600933-10-17-2023-14-AS-CYAG-CWPMJ4-20231017093831

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600933
Report Date: 10/14/2023
Date Signed: 10/17/2023 09:38:39 AM

Document Has Been Signed on 10/17/2023 09:38 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:	PACIFIC CARE HOME III		FACILITY NUMBER:	415600933
ADMINISTRATOR:	ICK, WILHELM O.		FACILITY TYPE:	740
ADDRESS:	2880 ST. CLOUD DRIVE		TELEPHONE:	(650) 615-9071
CITY:	SAN BRUNO	STATE: CA	ZIP CODE:	94066
CAPACITY:	6	CENSUS: 6	DATE:	10/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Melody Corpuz, Orlando Lizardo, and Moddie Andaya		TIME COMPLETED:	03:30 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	Unannounced annual visit made out to this facility on 10/14/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility caregivers, Melody Corpuz and Orlando Lizardo, who were requested to go ahead and contact the facility designated Administrator Wilhelm Ick to inform him that CCL was present at this time. The facility designated Administrator, Wilhelm Ick, arrived shortly thereafter to this facility along with co-Administrator Moddie Andaya while this LPA was conducting this annual visit. Brief interview was conducted with the facility designated Administrator and co-Administrator at this time. Current census was 6 residents. It was learned that there weren't any residents under the care of hospice at this time. This facility was approved for a hospice waiver to be able to accept and retain up to (2) residents under hospice care at any given time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Wilhelm Ick. The administrator certificate was due to expire on 03/22/2024 and in compliance at this time. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility caregiver Melody Corpuz. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperature was taken and measured to make sure that it was within the allowed range of 105-120 degrees. Linen closet, located in the hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

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: PACIFIC CARE HOME III	FACILITY NUMBER: 415600933
	VISIT DATE: 10/14/2023

NARRATIVE

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Garage area was toured. This area also housed the washing machine and dryer for this facility's use at this time. Laundry area was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers (2), located in facility kitchen area and entrance area, were reviewed to see if they had been annually inspected, or recently purchased, by the local fire extinguisher company at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of (5) facility resident records was conducted.
A review of (5) facility staff records was conducted.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the facility co-Administrator at this time.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 09:38 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: PACIFIC CARE HOME III	FACILITY NUMBER: 415600933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation while touring this facility, the licensee did not comply with the section cited above in that cleaning solutions, detergents, and cleaning supplies were found to be under restrooms sinks, kitchen sink, and the garage area where they were not secured and made accessible to the residents which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/15/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all cleaning solutions, detergents, and cleaning supplies will always be stored and made inaccessible to the residents at all times. All cleaning supplies will be removed and relocated to storage areas which will be properly locked and made inaccessible to the residents in care. A statement of correction, along with pictures of newly installed locks on the garage doors, will be completed and submitted into CCL by the due date.

Section Cited

Storage Space


	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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/17/2023 09:38 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: PACIFIC CARE HOME III	FACILITY NUMBER: 415600933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in [1] out of [5] facility personnel files did not have updated, and certified, first aid training which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all staff providing care and supervision to the residents will be trained in First Aid. A statement of correction will be completed, along with copies of completed updated First Aid training, will be submitted into CCL by the due date.

Type A

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 record review, the licensee did not comply with the section cited above in that [3] out of [5] residents diagnosed with dementia did not have a required updated annual medical assessment which posed an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/21/2023
	Plan of Correction
1 2 3 4	The facility designated Administrator stated that all residents diagnosed with dementia will be scheduled, with their respective licensed medical professionals, to be reappraised to address any changes, if any, to their care needs. A statement of correction, along with copies of updated medical assessments for dementia diagnosed residents, to be completed and submitted into CCL by the 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: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2023

LIC809 (FAS) - (06/04)

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