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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601000
Report Date: 10/08/2024
Date Signed: 10/09/2024 02:59:06 PM

Document Has Been Signed on 10/09/2024 02:59 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:SOLEDAD'S HOMEFACILITY NUMBER:
415601000
ADMINISTRATOR/
DIRECTOR:		BELONG, RACHELFACILITY TYPE:
740
ADDRESS:2880 BERKSHIRE DRIVETELEPHONE:
(650) 454-9905
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
10/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Glenda TalaTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On October 8, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. Upon entrance, LPA was greeted by caregivers, Glenda Tala and Hanna Soriano and LPA explained the purpose of the visit. The administrator, Rachel Belong and the house manager, Ryan Belong arrived and assisted with the inspection .

LPA toured the facility inside and outside including the bedrooms (4 private rooms), 2 full- bathrooms, kitchen, living and dining rooms. All outdoor and indoor passageways were observed to be free of obstruction. Bedrooms were equipped with the required furniture for residents to use. Bathrooms are equipped with grab bars, but no nonskid mats. Facility temperature is comfortable.

Central stored medication, and sharps objects were observed to be locked and inaccessible to residents. The left door of the chemical storage cabinet underneath the sink was observed to be not locked.

Emergency drills, central stored medication, and staff training records were reviewed.

Food supplies were observed to be adequate.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced May 17, 2024.

During today's inspection, there are 2 residents present and 2 are attending the adult day program.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
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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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: SOLEDAD'S HOME
FACILITY NUMBER: 415601000
VISIT DATE: 10/08/2024
NARRATIVE
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During the tour, LPA observed resident #1 (R1) was sitting in the wheelchair with an installed seat belt that was tied around R1's hip area. According to staff/manager, the seat belt was placed to prevent R1 from getting out of the wheelchair by him/herself. R1 was not able to release the seat belt.

LPA observed both full-bathrooms have a white mental plate underneath the sink and the plates have rusty spots on it. LPA observed the bathroom by R1 has chipped paint and wood around the base board trims.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/09/2024 02:59 PM - It Cannot Be Edited


Created By: Murial Han On 10/08/2024 at 11:44 AM
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: SOLEDAD'S HOME
FACILITY NUMBER: 415601000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms 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
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2
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed the left door of the chemical storage cabinet underneath the sink was observed to be not locked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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2
3
4
The administrator/licensee will develop a plan to ensure chemicals are locked at all times and will submit a copy of the plan to CCL by 10/9/2024 and the plan shall include staff training.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/09/2024 02:59 PM - It Cannot Be Edited


Created By: Murial Han On 10/08/2024 at 11:44 AM
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: SOLEDAD'S HOME
FACILITY NUMBER: 415601000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
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4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed both full bathrooms have a white mental plate underneath the sink and the plates have rusty spots. LPA observed the bathroom by R1's room has chipped paint and wood around the base board trims. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure the above observations are corrected and will provide photos of correction to CCL by 10/15/2024.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed both full bathrooms did not have non-skid mats in the shower which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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4
The administrator/licensee will develop a plan to ensure non-skid mats are in the bathroom/shower rooms at all times and will submit the plan and photos to CCL by 10/15/2024 and the plan shall include staff 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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/09/2024 02:59 PM - It Cannot Be Edited


Created By: Murial Han On 10/08/2024 at 11:51 AM
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: SOLEDAD'S HOME
FACILITY NUMBER: 415601000

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(2)
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions.(2)Postural supports shall be fastened or tied in a manner that permits quick release by the resident

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed R1 was sitting in a wheelchair with a seat belt tied around the hip area and R1 was not able to release it which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2024
Plan of Correction
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The administrator/resident will develop a plan to ensure compliance and in the plan, it shall indicate what are the measures that the facility will take to ensure R1's safety, what is the plan for the seat belt and it shall include staff training. The administrator/licensee will submit a copy of the plan to CCL by 10/9/2024.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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