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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600993
Report Date: 05/31/2024
Date Signed: 05/31/2024 01:58:02 PM


Document Has Been Signed on 05/31/2024 01:58 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:PACIFIC CARE HOME IVFACILITY NUMBER:
415600993
ADMINISTRATOR:JISON, RAFAELFACILITY TYPE:
740
ADDRESS:92 WEST 41ST AVENUETELEPHONE:
(650) 477-2474
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY:6CENSUS: 5DATE:
05/31/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Yolanda Campbell and Moddie AndayaTIME COMPLETED:
02:00 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds, consisting of 6 private client bedrooms--all with full private bathrooms--and 2 staff bedrooms--one staff room has 2 beds and the other has 3 beds. The common area consists of living/dining area and kitchen. Laundry and storage area is adjacent to a staff room.
No accessible bodies of water or fire safety hazards observed. PPE supply consists of surgical masks and gloves only. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. An updated Disaster and Mass Casualty Plan is posted. There are 5 residents present, and 3 staff. Four residents are receiving hospice services. Client records and staff records are reviewed, including criminal record clearances or exemptions for facility staff. Rafael Jison is a certified RCFE administrator that oversees facility operations.

The following updated form is requested to be submitted to CCLD BY 6/7/24:

• LIC 309 Administrative Organization

Proof of current Liability Insurance is given to LPA today, along with LIC 308, LIC610, LIC500.


Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
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 05/31/2024 01:58 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: PACIFIC CARE HOME IV
FACILITY NUMBER: 415600993

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree 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, as hot water temperature in bathroom in room #5 is tested at 124 degrees F, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/03/2024
Plan of Correction
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Hot water temperature will be lowered and maintained between 105 and 120 degrees F. Proof of correction to be submitted to CCLD BY 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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