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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601011
Report Date: 04/09/2024
Date Signed: 04/09/2024 01:22:56 PM

Document Has Been Signed on 04/09/2024 01:22 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:ALLIANCE CARE HOMEFACILITY NUMBER:
415601011
ADMINISTRATOR/
DIRECTOR:		MONTIEL, ALDOFACILITY TYPE:
735
ADDRESS:935 FOOTHILL DRIVETELEPHONE:
(415) 606-3215
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 4CENSUS: 4DATE:
04/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH:Aldo Montiel, Administrator and Diem Nguyen, NurseTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On April 9, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Diem Nguyen, Licensed Vocational Nurse(LVN) and explained the purpose of his visit. Administrator/Licensee, Aldo Montiel arrived later during the visit.

LPA Calandra toured the physical plant. This is a 1 story building with 4 bedrooms, two bathrooms, a kitchen, living room, dining room, garage and front and backyards. No accessible bodies of water or hazards were observed during the facility tour. In the backyard, LPA Calandra observed trash cans by the side of the house obstructing the emergency exit/passageway. Administrator/Licensee, Aldo Montiel relocated the trash cans in the presence of the LPA. In addition, LPA Calandra observed the gate to the front of the home had a padlock on it. Licensee/Administrator, Aldo Montiel had the lock removed in the presence of the LPA. The facility was maintained at a comfortable temperature of 72 degrees Fahrenheit. All fire alarm/carbon monoxide detectors were observed to be in working order. The fire extinguishers in the facility were observed to be fully charged and last checked on July 12, 2023. Night lights in the hallways were also observed to be in working condition. All bedrooms had the required furniture. Hot water temperature was measured at 113 degrees Fahrenheit well within the required range. The facility has the required 7 days of non-perishables and 2 days of perishables on hand. No food was expired. LPA Calandra observed that the refrigerator and freezer were missing temperature thermometers or devices that can determine the temperature of the appliance.

LPA Calandra reviewed 4 client records. All were observed to be complete except two client records (R1 and R2) which were missing Annual Needs and Services/Individual Program Plans(IPP).

LPA Calandra also reviewed 5 staff records. S1 and S2's records were observed to be missing the LIC 503-Health Screening Report. S1 and S2's records were also missing documentation of TB clearance.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/09/2024
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: ALLIANCE CARE HOME
FACILITY NUMBER: 415601011
VISIT DATE: 04/09/2024
NARRATIVE
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LPA Calandra interviewed 1 client and 2 staff.

LPA Calandra requested the following documents be faxed and/or provided:

- LIC 503-Health Screening Reports for all staff
-An updated LIC 500
-A copy of the Administrator's certificate

LPA Calandra received a copy of the Administrator's certificate from the Licensee/Administrator, Aldo Montiel during the visit.

A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

One Type A citation was provided for not having a temperature gauge in the refrigerator to ensure it is maintained at the required temperature per regulations.

A Type B citation was provided for not having IPP/Annual Needs and Services plans for two clients (R1 and R2).

A Type B citation was also provided for not having Health Screening Reports and TB results for 2 staff members (R1 and R2).

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

The Annual will be completed at a later date.

This report was reviewed with Administrator/Licensee, Aldo Montiel and a copy of the report along with Appeal rights, left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/09/2024 01:22 PM - It Cannot Be Edited


Created By: John Calandra On 04/09/2024 at 12:43 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: ALLIANCE CARE HOME
FACILITY NUMBER: 415601011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(10)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (10) A health screening as specified in Section 80065(g).

This requirement is not met as evidenced by:
Deficient Practice Statement
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CCR 80066(a)(10): Personnel Records: Based on record review, the licensee did not comply with the section cited above in 2 out of 5 staff records, which were observed to be missing the LIC 503-Health Screening report and TB results, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
Type B
Section Cited
HSC
1565(e)(2)
Other Provisions
(e) A facility shall have all of the following information readily available during an emergency: (2) An appraisal of needs and services plan for each individual served by the facility.

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 2 out of 4 client records, which were observed to not contain an Annual Needs and Service Plan or Individual Program Plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office 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:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 04/09/2024 01:22 PM - It Cannot Be Edited


Created By: John Calandra On 04/09/2024 at 12:46 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: ALLIANCE CARE HOME
FACILITY NUMBER: 415601011

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
85076(d)(2)


This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
CCR 85076(d)(2): Food Service: Based on observation and interview with the Administrator/Licensee, the licensee did not comply with the section cited above in 1 out of 1 refrigerators which was observed to be missing a thermometer or temperature taking device, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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:Cara Smith
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024


LIC809 (FAS) - (06/04)
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