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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601049
Report Date: 05/12/2023
Date Signed: 05/12/2023 12:41:36 PM


Document Has Been Signed on 05/12/2023 12:41 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HEIRLOOM ROSE GARDENFACILITY NUMBER:
415601049
ADMINISTRATOR:SUNPAYCO, EDMUNDFACILITY TYPE:
740
ADDRESS:2305 TIPPERARY AVETELEPHONE:
(707) 315-9728
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY:6CENSUS: 6DATE:
05/12/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Edmund SunpaycoTIME COMPLETED:
12:50 PM
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On May 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced follow up plan of correction visit. LPA met with Administrator, Edmund Sunpayco, and explained the purpose of the visit.

On 5/5/23, LPA Charitra and LPA Donato conducted an plan of correction visit to confirm facility's compliance with the citations that were issued on 4/21/23. Civil penalties for the following deficiencies; CCR 87468.2(a)(20), CCR 87211(a)(1), and CCR 87309(a) were assessed due to Licensee failing to provide CCL a plan of correction by due date. A total civil penalty of $2,100.00 was assessed for all 3 deficiencies ($700 for each deficiency).

On 5/5/23, the Licensee submitted plan of corrections for deficiencies; CCR 87211(a)(1), and CCR 87309(a). Deficiencies are now verified as corrected and cleared. Civil penalties are stopped on 5/5/23.

On 5/8/23, the Licensee submitted plan of corrections for deficiency; CCR 87468.2(a)(20). Civil penalty will be assessed from 5/6/23 through 5/8/23 for violation: 87468.2(a)(20) Additional Personal Rights of Residents in Privately Operated Facilities Personal Rights of Residents in All Facilities.A total of $300.00 is assessed today. Civil penalties are stopped on 5/8/23.

Report is reviewed with Administrator and a copy is provided with appeal rights. A copy of civil penalty is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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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