<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600982
Report Date: 01/09/2024
Date Signed: 01/09/2024 01:38:54 PM

Document Has Been Signed on 01/09/2024 01:38 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:FOCUS DAY PROGRAM IIFACILITY NUMBER:
415600982
ADMINISTRATOR:RUIZ, YOLANDAFACILITY TYPE:
775
ADDRESS:575 PRICE AVENUETELEPHONE:
(650) 362-3990
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94063
CAPACITY: 60CENSUS: 52DATE:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Program Director, Maria Villacorta TIME COMPLETED:
02:00 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
On January 9, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Program Director, Maria Villacorta and Program Supervisor, Evelyn Raz and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water observed. There are 6 activity/classroom areas. Rooms were observed to be clean, clear from tripping hazards, and spacious. Clients were observed to be participating in group activities with a sufficient amount of staff supervising. LPA observed 4 single bathrooms to be clean and odor-free. 3 office rooms and one conference room was observed. Changing room was observed to be clean and odor-free.

Kitchen was observed. LPA observed kitchen door locked unless staff is present. According to the Program Director, clients bring their lunches to the day program. Clients are able to store their lunches in the refrigerator. LPA observed chemical bottle on the kitchen floor not stored away and accessible to clients. Kitchen was observed to be clean and free from pests and flies. Sharps were observed to be stored appropriately and inaccessible to clients. Staff break room was observed to be locked. Room was overall clean, however LPA observed another chemical bottle on the floor not stored away. Medication was observed to be locked and inaccessible.

LPA toured the beauty room and observed a bottle of acetone on the table, open and accessible to clients in care. LPA toured the garage and observed indoor garage to be cluttered with boxes, trash bags and furniture. There was no walking room for LPA.

LPA checked all fire extinguishers which were inspected on 05/2023. Two Carbon monoxide detectors were observed to not be in working condition. First aid kit was observed to be present. There are a total of 6 facility vans that get serviced every 3 months. Last service date was December 11, 2023. LPA reviewed facilities emergency disaster plan. The last disaster drill was conducted on July 10, 2023. (continue to 809C)
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
Document Has Been Signed on 01/09/2024 01:38 PM - It Cannot Be Edited


Created By: Komal Charitra On 01/09/2024 at 12:51 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: FOCUS DAY PROGRAM II
FACILITY NUMBER: 415600982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1503.2
General Provisions
Every facility licensed or certified pursuant to this chapter shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observations, LPA observed two carbon monoxide detectors to not be in good working condition which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Licensee/Program Director to replace the carbon monoxide detectors and ensure it's working. Photo of new carbon monoxide detectors shall be submitted to LPA by 1/10/2024.
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, 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 observations, LPA observed a chemical bottle in the kitchen and staff the break room on the floor not stored away and accessible to clients. In addition, LPA observed a bottle of acetone on the table in the beauty room open and accessible to clients which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Program Director immediately locked all chemicals in LPAs presence. Facility to conduct an in-service training with staff regarding the importance of locking and storing chemicals appropriately. In-service training sign-in sheet shall be submitted by 1/10/2024.
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
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/09/2024 01:38 PM - It Cannot Be Edited


Created By: Komal Charitra On 01/09/2024 at 12:51 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: FOCUS DAY PROGRAM II
FACILITY NUMBER: 415600982

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(c)
Buildings and Grounds
(c) All outdoor and indoor passageways, stairways, inclines, ramps, open porches, and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, LPA observed the garage to be cluttered with boxes, furniture, and trash bags, with no walking room for LPA which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Licensee/Program Director shall submit a written plan regarding how to ensure garage is kept free from obstruction and fire safety hazards. In addition, facility shall submit a picture of the garage to LPA once garage is free from obstruction.
Type A
Section Cited
CCR
82065(f)
Personnel Requirements
(f) All personnel shall be given on-the-job training or shall have related experience providing knowledge of and skill in the following areas, as appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on 5/5 staff records reviewed, LPA did not observe any on-the-job training or any in-service trainings which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/10/2024
Plan of Correction
1
2
3
4
Licensee/Facility Director shall submit a written plan to ensure staff are receiving on-the-job training. This plan shall include training topics, how often trainings will be conducted, and who will be providing the training.
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
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 6
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: FOCUS DAY PROGRAM II
FACILITY NUMBER: 415600982
VISIT DATE: 01/09/2024
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
26
27
28
29
30
31
32
LPA reviewed 5 client files and all records reviewed were up to date and current. LPA reviewed 5 staff files. 1/5 staff file reviewed did not have record of TB testing, however health screening was observed present. In addition, 5/5 staff files reviewed did not have record of on-the-job training/ in-service training.

The following updated forms shall be submitted to CCLD by 1/16/2024:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Program Director and a copy is provided with appeal rights.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6