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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601026
Report Date: 11/18/2021
Date Signed: 11/19/2021 09:07:20 AM

Document Has Been Signed on 11/19/2021 09:07 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EARLY HORIZONS HOME CAREFACILITY NUMBER:
415601026
ADMINISTRATOR:ROGAYAN, YOLANDAFACILITY TYPE:
740
ADDRESS:2800 SHANNON DRTELEPHONE:
(650) 255-5418
CITY:S SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 6CENSUS: 4DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Yolanda RogayanTIME COMPLETED:
01:30 PM
NARRATIVE
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On November 18, 2021, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. Upon arrival, LPA did not see any COVID-19 signage posted at the front door. LPA was greeted by staff member Purificacion Gotera, and Administrator, Yolanda Rogayan joined shortly there-after. LPA Charitra explained the purpose of the visit. LPA was not screened at the front door and the Administrator was not able to provide LPA with visitor screening log documentation.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are not present: COVID-19 signage, entry procedures, staff face coverings, daily monitoring for residents and staff, visitor log documentation, and 30-day PPE supply.

LPA observed 2 bathrooms, both of which are equipped with hand washing signs, liquid soap, paper towels, and a covered trash bin. LPA observed 4 semi-private rooms with beds 6ft apart from eachother. There was a lack of COVID-19 signage throughout the facility. More signs should be posted in the facility hallway. A comfortable temperature is maintained and lighting is sufficient for comfort.

During the tour, the medication and sharps cabinet was unlocked. Sharps were observed to be present in the sink. Medication was observed to be out on the table accessible to residents. LPA immediately told Administrator to lock both sharps and medication so it is inaccessible to residents. LPA observed clean linen present and first aid kit to be completed.

LPA requests the following documents to be sent by 11/25/2021:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administration Certificate
  • LIC610E Emergency Distaster Plan

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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 11/19/2021 09:07 AM - It Cannot Be Edited


Created By: Komal Charitra On 11/18/2021 at 12:39 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: EARLY HORIZONS HOME CARE
FACILITY NUMBER: 415601026

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309


This requirement is not met as evidenced by: 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. Medication should be locked and inaccesible to residents.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. Facility failed to lock medication and sharps, somewhere inaccesible to residents. Facility failed to lock sharps and medication so it is inaccesible to residents.
POC Due Date: 11/29/2021
Plan of Correction
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Administrator will go over policies and regulations regarding storage space at facility. Administrator will review with staff why leaving medication and sharps accesible to residents can pose a serious health risk for residents.
Type A
Section Cited
CCR
87468.1(a)(2)


This requirement is not met as evidenced by:

This requirement is not met as evidenced by: Facility failed to provide post signage at the front entrance; facility failed to screen visitors upon entrance; facility failed to provide documentation on visitor, resident, and staff screening; facility failed to enforce masking with staff
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care. failed to provide documentation for daily resident and staff screening logs; failed to provide documentation for visitor screening log; residents and staff not wearing masks; entrance screening procedures; failure to wear face coverings, failure to monitor daily symptom screening for staff and residents; failure to maintain a 30-day supply of PPE
POC Due Date: 11/25/2021
Plan of Correction
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The administrator/licensee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening for residents and staff members, masking guidance, COVID-19 protocol signage, and maintaining an adequate amount of PPE supply. (TYPE B Citation)
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:Julio Montes
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2021


LIC809 (FAS) - (06/04)
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