415600983-7-12-2022-14-AS-KCHA-CG9QNG-20220712121908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600983
Report Date: 07/12/2022
Date Signed: 07/12/2022 12:19:17 PM

Document Has Been Signed on 07/12/2022 12:19 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	ANAMARIE CARE HOME LLC		FACILITY NUMBER:	415600983
ADMINISTRATOR:	AREVALO, ANA MARIE		FACILITY TYPE:	740
ADDRESS:	748 WASHINGTON STREET		TELEPHONE:	(650) 550-4668
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	6	CENSUS: 5	DATE:	07/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Ana Marie Arevalo		TIME COMPLETED:	12:30 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 July 12, 2022, Licensing Program Analysts (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Administrator, Ana Marie Arevalo and explained the purpose of the visit. Upon arrival, LPA was screened at entry point and observed the COVID-19 signage posted on the front door. Administrator was able to provide LPA with screening log documentation for visitors, however was unable to provide screening log documentation for staff and residents. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed one staff member during the visit without a face covering. This is a single story home with 3 resident bedrooms, 2 staff bedrooms and 2 bathrooms. LPA observed 2 out of 3 resident bedrooms to be shared rooms with beds 6ft apart. LPA observed the bathrooms to be equipped with hand-washing signs and liquid soap, however advised Administrator to remove bar soaps, hand-towels, bath-towels, and ensure trash cans have a fitted lids and paper towels in all shared bathrooms. LPA observed the COVID-19 signage posted throughout the facility. LPA observed medications and toxins locked and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable present. LPA observed sharps drawer to be unlocked and accessible to residents. A comfortable temperature is maintained and lighting is sufficient for comfort. First aid kit was observed to be present and first aid cards were observed to be current. LPA toured the garage and observed washer and dryer to be in good working condition. LPA also observed the 30-day PPE supply present. CONT. to 809C.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ANAMARIE CARE HOME LLC	FACILITY NUMBER: 415600983
	VISIT DATE: 07/12/2022

NARRATIVE

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LPA requests the following forms to be sent to CCLD by 7/19/22:

LIC308 Designation of Administrative Responsibility
LIC309 Administrative Organization
LIC500 Personnel Report
LIC610E Emergency Disaster Plan
Administrator Qualifications

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with Administrator, and a copy is provided. Appeals Rights were given.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 07/12/2022 12:19 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: ANAMARIE CARE HOME LLC	FACILITY NUMBER: 415600983
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia: (f)The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the licensee did not comply with the section cited above as the sharps drawer was observed to be unlocked which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2022
	Plan of Correction
1 2 3 4	Facility administrator will lock the drawer with the sharps or move them to a locked cabinet so it is inaccessible to residents

Type A

Section Cited

CCR

87468.1(a)(2)

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and documentation review, the facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to ensure all staff wear a face mask which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/13/2022
	Plan of Correction
1 2 3 4	The Administrator and/or designee will review the Department's Provider Information Notices (PINs) regarding face coverings and the daily COVID-19 screening process for residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done. The Administrator will in-service staff members on this procedure and the Administrator will provide a copy of the sign-in sheet and the required logs to the Department by 7/13/22.

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: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022

LIC809 (FAS) - (06/04)

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