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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600974
Report Date: 06/17/2024
Date Signed: 06/17/2024 07:08:26 PM


Document Has Been Signed on 06/17/2024 07:08 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:KIMOCHI SAN MATEOFACILITY NUMBER:
415600974
ADMINISTRATOR:CHAN, LINDA ISHIIFACILITY TYPE:
740
ADDRESS:453 N SAN MATEO DRIVETELEPHONE:
(650) 388-7130
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:14CENSUS: 13DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Linda Ishii ChanTIME COMPLETED:
07:15 PM
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LPA Audrey Jeung toured facility and grounds, consisting of 11 client bedrooms, 3 of which are shared--all with full private bathrooms. All but 3 rooms have direct access to enclosed paved patio. No accessible bodies of water or fire safety hazards observed. PPE supply is adequate and first aid kit is complete. Perishable and non-perishable food supply is maintained. Infection control signs are prominently posted. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Hot water temperature is tested at 120 degrees in public bathroom. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. Liquid soap is available at all sinks. An updated Disaster and Mass Casualty Plan is accessible to staff. There are 13 residents present, and 2 caregivers. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Linda Ishii-Chan is a certified RCFE administrator that oversees facility operations.
Staff and client files are reviewed.

The following updated forms/information are requested to be submitted to CCLD BY 7/1/24:

• LIC 309 Administrative Organization
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report

The following information is provided to LPA:

• Proof of current Liability Insurance
• Page 9 of Emergency Disaster Plan (LIC610E)

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on a following page. See also 2 Technical Advisiory Notes.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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 06/17/2024 07:08 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: KIMOCHI SAN MATEO
FACILITY NUMBER: 415600974

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of staff training records, the licensee did not comply with the section cited above, as 4 out of 4 staff files reviewed were missing training on postural supports, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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Proof of required training on postural supports will be sent to CCLD BY DUE DATE for 4 staff.
Type B
Section Cited
CCR
87608(a)(3)
POSTURAL SUPPORTS

A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of client records, the licensee did not comply with the section cited above, as clients #1 and #4 have half bed rails, but there are no MD orders maintained. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/01/2024
Plan of Correction
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MD orders for half bed rails for clients #1 and #4 will be sent to CCLD BY 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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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