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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601005
Report Date: 08/06/2024
Date Signed: 08/06/2024 07:30:04 PM

Document Has Been Signed on 08/06/2024 07:30 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:SANDPIPER HOMEFACILITY NUMBER:
415601005
ADMINISTRATOR/
DIRECTOR:		ELISEO, ALDRINFACILITY TYPE:
735
ADDRESS:238 SANDPIPER CTTELEPHONE:
(650) 389-6828
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 4CENSUS: 4DATE:
08/06/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Caregiver, Gracia SantosTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On August 6, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by lead staff, Gracia Santos and LPA explained the propose of today's visit. The administrator, Aldrin Eliseo arrived shortly thereafter and assisted with the inspection.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. This is a single story facility with 4 private resident rooms and 2 full bathrooms. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four private resident rooms to be spacious and included all required furnishings. Two full bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Extra linen was present.

LPA medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Egress delayed door alarms were observed to be in good repair.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in May 13, 2024. Fire drill records were reviewed.

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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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 08/06/2024 07:30 PM - It Cannot Be Edited


Created By: Murial Han On 08/06/2024 at 02:25 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: SANDPIPER HOME
FACILITY NUMBER: 415601005

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80086(a)


This requirement is not met as evidenced by: 80086 Alterations to Existing Building or New Facilities



(a) Prior to construction or alterations, all licensees shall notify the licensing agency of the proposed change.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as based on the facility sketch, LPA observed the storage room was convert into an office with files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/13/2024
Plan of Correction
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The administrator/licensee will develop a plan to address the observation that was identified and will submit a copy of the plan to CCL by 8/13/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024


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: SANDPIPER HOME
FACILITY NUMBER: 415601005
VISIT DATE: 08/06/2024
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LPAs reviewed P& I/ Case Resource Records for 4 residents to be adequate.

During today's inspection, there is 1 residents present and 3 are attending the day program.

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 the administrator. A copy of the report and appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024
LIC809 (FAS) - (06/04)
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