415600984-9-20-2022-14-AS-KCHA-CJFTE9-20220920143935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600984
Report Date: 09/20/2022
Date Signed: 09/20/2022 02:39:45 PM

Document Has Been Signed on 09/20/2022 02:39 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:	HOLLAND HOUSE		FACILITY NUMBER:	415600984
ADMINISTRATOR:	BONIFACIO, JOANN		FACILITY TYPE:	740
ADDRESS:	2634 HOLLAND STREET		TELEPHONE:	(650) 341-0121
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 5	DATE:	09/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	Caregiver, Angelina Rafael		TIME COMPLETED:	02:48 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 September 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted on the front door. LPA met with Caregiver, Angelina Rafael and explained the purpose of the visit. LPA was screened at entry point and caregiver was able to provide LPA screening log documentation for residents and staff. LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 5 resident rooms, 1 full bathroom, 4 half baths, 1 office room, and 1 staff room. LPA observed all resident rooms, 4 were observed to be private and one was observed to be shared with beds 6ft apart from each other. LPA toured the facility bathrooms and observed liquid soap and hand-washing signs, however LPA advised caregiver to not keep bar soaps and hand-towels but ensure that all bathrooms are equipped with liquid soap and paper-towels. In addition, LPA advised caregiver to ensure all trash cans have a fitted lid. LPA toured the living room and dining room and it was clear and odor-free. The living room was free from any tripping hazards. A comfortable temperate at 76 degrees F was maintained. Lighting was sufficient for comfort. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Sharps and toxins were observed to be locked and inaccessible to residents. Extra linen was observed to be present. LPA observed the medications located in a cabinet in the office room to be unlocked an accessible to residents. Caregiver immediately locked the medication cabinet in LPA's presence. LPA observed washer and dryer to be in good repair. During the visit, LPA observed all staff with a face covering. Infection control practices are reviewed: COVID signage throughout the facility, face coverings, 30-day PPE supply, entry procedures, daily monitoring records for staff, residents and visitor. CONT. to 809C.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

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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Document Has Been Signed on 09/20/2022 02:39 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HOLLAND HOUSE	FACILITY NUMBER: 415600984
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, the facility did not comply with the section cited above as medication cabinet was observed to be unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 09/21/2022
	Plan of Correction
1 2 3 4	Facility immediately locked medications in LPA's prescense during the visit. Facility administrator to conduct in-service training with staff regarding the importance of locking medications and will provide LPA with attendance sheet by 9/23/22.

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance: (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, it was found that S1 is not fingeprrint cleared and/or associated to the facility, however S1 is providing care to residents. Facility failed to ensure the S1 is associated prior to working which poses an immediate health and safety risk for residents in care.
	POC Due Date: 09/21/2022
	Plan of Correction
1 2 3 4	Facility to ensure S1 does not work at the facility until S1 is fingerprint cleared and associated to the facility. Facility to submit a plan to ensure deficiency does not repeat in the future.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: HOLLAND HOUSE	FACILITY NUMBER: 415600984
	VISIT DATE: 09/20/2022

NARRATIVE

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During the visit, LPA found that S1 is not fingerprint cleared or associated to the facility. It was indicated that S1 got fingerprinted, however has still not received clearance. This violation results in a civil penalty of $100 x 2 days = $200.

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.

LPA requests the following forms to be submitted to CCLD by 9/27/22:
-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-LIC610E Emergency Disaster Plan
-Administrator Certificate

Report is reviewed with Caregiver and a copy is provided with appeals rights. A copy of the civil penalty is also given to the facility.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2022

LIC809 (FAS) - (06/04)

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