415600933-4-23-2024-14-AS-MHAN-D4LPPK-20240423112940

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600933
Report Date: 04/23/2024
Date Signed: 04/23/2024 06:07:11 PM

Document Has Been Signed on 04/23/2024 06:07 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 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: 4	DATE:	04/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Caregiver, Emily Soriano		TIME COMPLETED:	11:45 AM

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 23, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Emily Soriano. LPA explained the purpose of the visit. Facility supervisor, Moddie Andaya arrived toward the end of the inspection and assisted with the rest of the inspection. LPA toured facility and grounds. No accessible bodies of water. 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. 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 107- 110 degrees F. 2 days for perishables and & 7 days non-perishable were observed to be present. During the tour of the garage, LPA observed chemicals were unlocked and accessible to residents. LPA also 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: futon beds, clothing, plastic shoe storage unit, closet, toiletries, and a blue luggage. Medication cabinet, located in the kitchen area, was reviewed. Chemical was observed to be unlocked underneath the kitchen sink. 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. Facility was not able to provide documentation that emergency drills were conducted.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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: PACIFIC CARE HOME III	FACILITY NUMBER: 415600933
	VISIT DATE: 04/23/2024

NARRATIVE

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Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last inspected on 10/19/2023.

A review of (4) facility resident records was conducted; A review of (2) facility staff records was conducted and 1 file was not available for review and according to the supervisor this staff just starting working at this facility yesterday and the file is still at one of the sister facilities.

During today's inspection, there were 4 residents and 2 staff present.

LPA requested these documents to be submitted by 4/24/2024: a copy of the administrator certification.

Civil penalty is being assess today for repeat violation during the annual inspection on 10/14/2023.

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 with administrator and supervisor. 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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2024 06:07 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 III	FACILITY NUMBER: 415600933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87305(a)

Alterations to Existing Buildings or New Facilities

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	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 garage has livable items such as toiletries, futon beds, personal hygiene items, clothing, shoes, etc. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	The administrator/licensee shall remove furniture, and personal items in the garage and provide photos to CCL by 4/24/2024 to ensure safety for residents and facility staff.

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) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed chemicals in the kitchen area and in the garage are unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	The administrator/licensee shall develop a plan to ensure compliance and send photos to CCL by 4/24/2024 to ensure all chemicals are locked and inaccessible to residents in care.

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/23/2024 06:07 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 III	FACILITY NUMBER: 415600933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able to provide documents that emergency drill were conducted which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/24/2024
	Plan of Correction
1 2 3 4	The administrator/licensee shall develop a plan to ensure drills are conducted accordingly and the plan shall include staff training. The administrator/licensee will provide a copy of the plan to CCL by 4/24/2024.

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 04/23/2024 06:07 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 III	FACILITY NUMBER: 415600933
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87755(c)

This requirement is not met as evidenced by: 87755 Inspection Authority of the Licensing Agency
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 3 staff personnel file was not available for review during the inspection which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/29/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will develop a plan to ensure staff files are available to inspect and provide a copy of the plan to CCL by 4/29/2024

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: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

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