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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601010
Report Date: 01/27/2025
Date Signed: 01/27/2025 06:08:11 PM

Document Has Been Signed on 01/27/2025 06:08 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/
DIRECTOR:		CRUZ DIAZ, ROWENAFACILITY TYPE:
740
ADDRESS:1024 NORTON STTELEPHONE:
(650) 477-2363
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY: 6CENSUS: 4DATE:
01/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Leo SisonTIME VISIT/
INSPECTION COMPLETED:
06:15 PM
NARRATIVE
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LPA Audrey Jeung toured facility and grounds of this 1-level home, consisting of 3 client bedrooms, staff room, two bathrooms, kitchen and living/dining room. There are 2 detached storage units in fenced backyard beyond covered patio. Washer and dryer are located outside on side of building, in covered walkway. There is one car garage. No accessible bodies of water or fire safety hazards observed. PPE supply is inspected. Food supplies are maintained. A comfortable temperature is maintained, lighting is sufficient for comfort and safety and hot water temperature tested at 107 degrees. Toilet and bathing facility is equipped with grab bars and nonskid flooring material. Liquid soap is available at bathroom sink. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 2 residents present and 1 staff. No one is currently receiving hospice services. Three client records are reviewed. One resident's file is not on site, as it is with administrator and client for annual review meeting. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed, including current first aid training and health screenings. Rowena Cruz Diaz has an expired RCFE administrator certificate (x 2018).

The following information/forms are provided:
- Proof of current liability insurance
- Designation of Administrative REsponsibility (LIC308)
- Personnel REport (LIC500)
- Emergency Disaster Plan (LIC610D)
- Infection Control Plan
- Proof of current surety bonding

Licensee is requested to submit the following information/forms to CCLD BY 2/10/25:
- Administrative Organization (LIC309)
- Bedridden plan of operation

Deficiencies of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 are observed and cited on following pages. Technical Advisory Note is also issued--1 page.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 01/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
Document Has Been Signed on 01/27/2025 06:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/27/2025 at 05:19 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87406(a)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on review of staff records, the licensee did not comply with the section cited above, as there is no certified administrator who maintains a RCFE administrator certificate, which poses an immediate health, safety or personal rights risk to persons in care.
Administrator certificate posted for staff #4 expired in 2018.
POC Due Date: 01/28/2025
Plan of Correction
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2
3
4
Plan of correction to be sent to CCLD BY DUE DATE.
Type A
Section Cited
CCR
87412(d)
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Duplicate citation.
POC Due Date: 01/28/2025
Plan of Correction
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2
3
4
See 87406, above.
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:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 01/27/2025 06:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/27/2025 at 05:19 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of staff records, the licensee did not comply with the section cited above in 3 out of 3 staff records reviewed, which poses/posed a potential health, safety or personal rights risk to persons in care.
- There is no evidence that staff have received any training in 2024, including dementia, postural supports, hospice care, restricted health conditions.
POC Due Date: 02/10/2025
Plan of Correction
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2
3
4
Plan/proof of correction to be sent to CCLD BY DUE DATE.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
DELETED
POC Due Date: 02/10/2025
Plan of Correction
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2
3
4
DELETED
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:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/27/2025 06:08 PM - It Cannot Be Edited


Created By: Audrey Jeung On 01/27/2025 at 05:19 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: 01/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of staff records, the licensee did not comply with the section cited above in 3 out of 3 staff records reviewed, which poses a potential health, safety or personal rights risk to persons in care.
- There is no evidence that staff have received 8 hours annual medication training.
POC Due Date: 02/10/2025
Plan of Correction
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2
3
4
Proof of annual medications training for staff will be sent to CCLD BY DUE DATE.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of facility records, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care.
- There is no confirmed documentation that disaster drills have been conducted since 2023.

POC Due Date: 02/10/2025
Plan of Correction
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2
3
4
Disaster drills shall be performed and documented quarterly. Proof of correction to be sent to CCLD BY DUE DATE.
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:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2025


LIC809 (FAS) - (06/04)
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