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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600970
Report Date: 10/10/2024
Date Signed: 10/10/2024 09:47:18 PM

Document Has Been Signed on 10/10/2024 09:47 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:CRESTMOOR HOMEFACILITY NUMBER:
415600970
ADMINISTRATOR/
DIRECTOR:		MARLU RAQUINIOFACILITY TYPE:
735
ADDRESS:3498 CRESTMOOR DRIVETELEPHONE:
(650) 387-9488
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
10/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Lead staff, Rudy MarcosTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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On October 10, 2024 Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. Upon entrance, LPA was greeted by caregiver, Karrie Mina and LPA explained the purpose of today's visit. Caregiver informed Licensee, Romar Raquino over the phone of LPA's visit. The lead staff, Rudy Marcos arrived shortly thereafter and assisted with the inspection.

LPA toured the facility inside and outside including the bedrooms (4 private rooms), 2 full- bathrooms, kitchen, living room and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, and non-skid mats. Facility temperature is comfortable. Hot water temperatures in the kitchen and bathroom was measured at 105- 108 degrees F.

Central stored medication, toxins and sharps objects were observed to be locked and inaccessible to residents.

Food supplies were observed to be adequate,

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were last inspected on 9/9/2024.

LPA reviewed P & I records for 4 residents to be adequate.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: CRESTMOOR HOME
FACILITY NUMBER: 415600970
VISIT DATE: 10/10/2024
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During today's inspection, there are 3 residents present and 1 was attending the adult day program.

During the tour of the facility, LPA observed an extended fence area beyond the fence that was on the facility sketch and in the extended fence, LPA observed two storage sheds/units and the one on the left side has electricity inside and consisted of a folding bed, staff shoes, a drawer with staff personal belongings, etc.

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 Licensee, Romar who arrived at the end of the visit, lead staff, Rudy and caregiver, Keemfaustin Mina.

A copy of the report is provided and appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2024 09:47 PM - It Cannot Be Edited


Created By: Murial Han On 10/10/2024 at 11:40 AM
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: CRESTMOOR HOME
FACILITY NUMBER: 415600970

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
80086(a)
80086 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.

This requirement is not met as evidenced by: LPA observed 2 storage units in the extended yard that is not reflected on the facility sketch; the storage unit on the left side consisted of electricity, staff personal belongings, etc.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 2 locked storage units in the extended yard that is not reflected on the facility sketch; the storage unit on the left side consisted of electricity, staff personal belongings, etc. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/11/2024
Plan of Correction
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The administrator/Licensee will submit a plan to ensure compliance and in the plan, it shall indicate the steps that the facility will take and the time frame to ensure the extended yard is safe for the residents and staff members. The administrator will provide a copy of the plan to CCL 10/11/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2024


LIC809 (FAS) - (06/04)
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