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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601010
Report Date: 01/17/2024
Date Signed: 01/17/2024 03:42:56 PM

Document Has Been Signed on 01/17/2024 03:42 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:AJAVINIAR HOME CARE SERVICES LLCFACILITY NUMBER:
415601010
ADMINISTRATOR:CRUZ DIAZ, ROWENAFACILITY TYPE:
740
ADDRESS:1024 NORTON STTELEPHONE:
(650) 477-2363
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 4DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Caregiver Leo SisonTIME COMPLETED:
03:45 PM
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On 01/17/2023, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with caregiver Leo Sison and explained the purpose of today's visit. LPA was informed upon entry that there is one COVID positive resident in care at this time. The resident is quarantined in their room. Infection control protocols are discussed and testing of residents and staff are conducted weekly.

LPA was allowed entry into the facility. This is a one level facility. Annual Fees are not current per review made on 01/09/2023 of facility file. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is organized and observed appliances are in good repair. Knives are stored under the kitchen sink locked and not accessible to residents. Spray bottle type cleaning supplies are also locked below the kitchen sing. Cleaning solutions are also locked in a cabinet outside of the facility adjacent to the washer and dryer. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and locked in a closet. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with, fire extinguisher located the back door adjacent to the kitchen, smoke detector/carbon monoxide detectors are observed in place in resident rooms and central hallway connecting resident rooms, and central heating system is operating. PPE and additional food supplies are observed as in place in the exterior shed of the facility. Laundry area is also observed as fully operational located outside of the facility under sheltered roofing. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature was measured at 112F in common resident bathroom.

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SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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 01/17/2024 03:42 PM - It Cannot Be Edited


Created By: Jaime Vado On 01/17/2024 at 03:23 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: AJAVINIAR HOME CARE SERVICES LLC

FACILITY NUMBER: 415601010

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 01/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87406(g)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 2 records reviewed, which poses an immediate health, safety or personal rights risk to persons in care. LPA observed that the adminstrator's certifacte expired on 10/05//2018. Administrator Certification Requirements - Certificates issued under this section shall be renewed every two (2) years provided the certificate holder has complied with all renewal requirements.
POC Due Date: 01/18/2024
Plan of Correction
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Administrator/Licensee shall submit an updated Administrator Certificate and/or proof of completion or proof of enrollment to renew administrator certifacte. Plan shall be received by due date specified.
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:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/17/2024


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: AJAVINIAR HOME CARE SERVICES LLC
FACILITY NUMBER: 415601010
VISIT DATE: 01/17/2024
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LIC809C - Annual

LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. COVID PPE and resident incontinence supplies are observed in place inside the facility as well as in storage areas outside of the facility. Disaster drill is conducted quarterly, last conducted on 06/06/2023. Facility does not handle resident monies. Administrator certificate is observed as expired on 10/05/2018.

The following updated forms are being requested to be received by 01/24/24:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance

Citation issued on the following LIC809D.
Report is reviewed with Leo Sison.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2024
LIC809 (FAS) - (06/04)
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