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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600979
Report Date: 11/19/2023
Date Signed: 11/21/2023 03:17:42 PM

Document Has Been Signed on 11/21/2023 03:17 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:GRATIA HOMEFACILITY NUMBER:
415600979
ADMINISTRATOR:LETRONDO, LILIBETHFACILITY TYPE:
735
ADDRESS:2585 WENTWORTH DRIVETELEPHONE:
(650) 580-1266
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 3DATE:
11/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rosemarie Pasang, Lillibeth Letrondo and Veronica Cochon TIME COMPLETED:
04:30 PM
NARRATIVE
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Unannounced annual visit made out to this facility on 11/19/2023 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Lillibeth Letrondo, at this time. A brief interview was conducted with the facility designated Administrator at this time.
It was learned that this facility was also vendorized through Golden Gate Regional Center to be able to accept and retain up to (4) Level 4I residents at any given time.
Current census was 3 residents.
There were no residents under the care of hospice or home health at this time according to statements made by the facility designated Administrator.
Tour of this facility was conducted.
A tour of the facility kitchen area was conducted. Drawers and cabinets were opened and the items enclosed were reviewed at this time. Drawers housing knives and sharps were reviewed to make sure that they were locked and made inaccessible to the residents at this time.
Cleaning agents, bleach, and other supplies were reviewed under kitchen sink to make sure that they were locked and made inaccessible to the residents at this time.
A review of the facility food supply was conducted. A review of the facility's 2-day perishable foods and 7-day nonperishable foods was conducted to make sure that there were sufficient quantities on hand at all times.
Medication cabinet, located in the kitchen area, was reviewed. Policies and procedures involving handling, dispensing, and documentation of the resident medications were discussed with the facility designated Administrator at this time. A review of the facility Medication Administration Record and dispensing log was conducted.
Medication cabinet was reviewed to make sure that it was locked and made inaccessible to the residents at this time.
Living room, dining area, and all other areas intended for resident use were observed to be furnished and maintained in compliance at this time and able to meet the needs of the residents.
A tour of the resident bedrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2023
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: GRATIA HOME
FACILITY NUMBER: 415600979
VISIT DATE: 11/19/2023
NARRATIVE
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A tour of the resident restrooms was conducted. Grab bars and non skid mats were observed to be present and in good repair at this time.
Hot water temperatures were taken to make sure that they measured within the allowed range of 105-120 degrees at all times.
Laundry room, located in the garage area, was observed to be locked since it did house additional detergents, soaps, or bleach at this time. It was learned that all cleaning and laundry supplies were locked and made inaccessible to the residents at this time.
Linen closet was reviewed. Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.
A tour of the garage area was conducted. Additional food storage units were observed to be present and in good repair at this time.
First aid kits were observed to be present and contained all of the required components at this time.
Fire extinguishers were observed to be placed throughout this facility and were inspected by the local fire authority, Imfeld Cloutier Fire Protection, on 07/19/2023 and found to be in compliance at this time.
A tour of the exterior grounds for this facility was conducted. A review of the facility perimeter fence, side gates, and exits was conducted.
A review of (3) resident files was conducted and noted on the LIC 858.
A review of (5) resident staff files was conducted and noted on the LIC 859.

The following forms and documents were requested to be updated and submitted into CCL in order to update this facility file:
  • 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 designated Administrator at this time.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/21/2023 03:17 PM - It Cannot Be Edited


Created By: Charlie Yang On 11/19/2023 at 03:46 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: GRATIA HOME
FACILITY NUMBER: 415600979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that the hot water that was measured in (2) facility resident restrooms were above the allowed range at 126.4 degrees which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/20/2023
Plan of Correction
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The facility designated Administrator stated that the hot water heater will be turned down immediately and the hot water will be measured on a daily basis for 7 days. A statement of correction, along with hot water measurements for the 7 days, will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 11/21/2023 03:17 PM - It Cannot Be Edited


Created By: Charlie Yang On 11/19/2023 at 03:46 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: GRATIA HOME
FACILITY NUMBER: 415600979

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in [3] out of [3] Medication Administration Records and dispensing logs were not properly documented by facility staff upon dispensing of the medications to the residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/26/2023
Plan of Correction
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The facility designated Administrator stated that a review of the Medication Administration Record and dispensing log will be reviewed to address all dates/times that were missing required initials in order to signify that the medications were dispensed as ordered by the physician. A statement of correction, along with proof of updated staff training for no less than one hour in duration, on the topic of handling, dispensing, and documentation of resident medications will be completed and submitted into CCL by the due date.
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:Liza King
LICENSING EVALUATOR NAME:Charlie Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 11/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2023


LIC809 (FAS) - (06/04)
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