415601049-5-5-2023-14-AS-KCHA-CRJPPB-20230505112917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601049
Report Date: 05/05/2023
Date Signed: 05/05/2023 11:29:28 AM

Document Has Been Signed on 05/05/2023 11:29 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	HEIRLOOM ROSE GARDEN		FACILITY NUMBER:	415601049
ADMINISTRATOR:	SUNPAYCO, EDMUND		FACILITY TYPE:	740
ADDRESS:	2305 TIPPERARY AVE		TELEPHONE:	(707) 315-9728
CITY:	SOUTH SAN FRANCISCO	STATE: CA	ZIP CODE:	94080
CAPACITY:	6	CENSUS: 4	DATE:	05/05/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Caregiver, Ivan Wanawan		TIME COMPLETED:	11:45 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On May 5, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citations that were issued on 4/21/23. LPAs met with Caregivers, I. Wanawan and A. Sunpayco and explained the purpose of the visit On 4/21/23, LPA Charitra and LPA Donato concluded a complaint investigation; complaint control #14-AS-20230106153247, which alleged that the licensee did not allow Resident #1 (R1) to return to the facility. The allegation was substantiated, and the licensee was cited for violating California Code of Regulations (CCR) Title 22, § “87468.2(a)(20)” Additional Personal Rights of Residents in Privately Operated Facilities for not allowing R1 to return back to the facility because the facility was experiencing staffing challenges. The plan of correction was due by 4/28/2023. On 4/21/23, LPA Charitra and LPA Donato conducted a case management visit and cited the facility for CCR 87211(a)(1) Reporting Requirements for facility failing to report an incident that occurred on 12/9/22. The plan of correction for this citation was due by 4/28/2023. On 4/21/23, LPA Charitra and LPA Donato conducted an annual visit and cited the facility for CCR 87309(a) Storage Space, 87705(f)(1) Care of Persons with Dementia, 87705(j) Care of Persons with Dementia. The plan of correction for these citation were due by 4/28/2023. During the visit today, LPAs toured the facility and observed knives and chemicals to be locked and inaccessible to residents. LPAs also observed the door alarms to be in good repair and working condition. During the visit administrator/co-administrator was not present, and caregivers were unable to provide LPAs with a POC for the following cited deficiencies; CCR 87468.2(a)(20), CCR 87211(a)(1), and CCR 87309(a). Continue to 809C

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HEIRLOOM ROSE GARDEN	FACILITY NUMBER: 415601049
	VISIT DATE: 05/05/2023

NARRATIVE

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Due to the above 3 deficiencies not being corrected, and documentation not being submitted to CCLD by 4/28/2023, a civil penalty is being assessed in the amount of $100 a day for EACH DEFICIENCY from 4/29/2023 through 5/5/2023 and will continue to accrue until corrected.

A total civil penalty of $2,100.00 is being assessed for all 3 deficiencies ($700 for each deficiency).

Report is reviewed with Caregivers, however Caregivers refused to sign. A copy is provided of reports and civil penalties with a copy of appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/05/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023

LIC809 (FAS) - (06/04)

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