415601049-4-21-2023-14-AS-KCHA-CR4SSC-20230421140742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601049
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:07:53 PM

Document Has Been Signed on 04/21/2023 02:07 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 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:	04/21/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Co-Administrator, Rose Lo		TIME COMPLETED:	02:20 PM

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 April 21, 2023, Licensing Program Analysts (LPA) Komal Charitra and Grace Donato conducted an unannounced annual inspection. LPA met with Caregivers, Mikhail Serrano and Angelo Sunpayco and explained the purpose of the visit. Administrator, Edmund Sunpayco and Co-Administrator, Rose Lo joined shortly thereafter. Upon arrival, LPA observed COVID signage posted on front door and temperatures were taken. LPAs toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 4 resident rooms and 2 full bathrooms. LPA toured the resident rooms and observed them to be private rooms with all required furntiure. LPAs observed resident room #3 to have an exit door with an alarm, however the alarm was observed to not be working. In addition, alarm was not working in the office room. Bathrooms were observed to be in good repair and equipped with non-skid mats. LPAs observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature of 68 degrees F is maintained and lighting is sufficient for comfort. Hot water temperature was measured at 110 degrees F throughout the facility. Staff training records were reviewed; food supplies were observed to be adequate. LPAs toured the kitchen, and observed sharps to be unlocked and accessible to residents. LPAs toured the garage and observed extra food, linen and resident supplies present. Washer and dryer was observed to be in good repair. LPAs observed toxins and chemicals to be unlocked and accessible to residents. According to staff, residents do not have access to the garage. LPAs advised caregivers to still keep chemicals locked. Facility is equipped with smoke detectors and a carbon monoxide detector. Fire extinguisher was last serviced November 3, 2022. Fire drill was last conducted in November of 2022 (Cont to 809C)

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

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: 04/21/2023

NARRATIVE

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All staff present at the facility was observed to have fingerprint clearance. Medications were observed to be locked and inaccessible to residents.

LPAs reviewed residents and staff records. Resident records contain admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal, Needs and Service Plan, etc. Staff files contain personnel records, health screening, COVID-19 vaccination card, Job Description, Abuse Statement, First Aid, training records. Criminal Record Statement, etc.

During the visit, 3 residents were observed in their rooms sleeping and one resident was observed in the dining room.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Co-Administrator and a copy is provided with appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/21/2023 02:07 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type B

Section Cited

CCR

87309(a)

Storage Space

(a) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, LPAs observed toxins and chemicals in the garage to be unlocked and accessible to residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Facility to lock the toxins and chemicals and provide LPA with a photo of locked chemicals. Facility to conduct in-service training regarding the important of storing chemicals and toxins in a locked area.

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, LPAs observed knives drawers to be unlocked and scissors to be in another drawer to be unlocked which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Facility to lock the knives and provide LPA with a photo of locked sharps. Facility to conduct in-service training regarding the important of locking sharps immediately especially when there is no staff present in the kitchen.

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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

Page: 2 of 7

Document Has Been Signed on 04/21/2023 02:07 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(j)

87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as door alarm for bedroom #3 (dementia resident's room) and office room was observed to not be in working condition which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/28/2023
	Plan of Correction
1 2 3 4	Facility administrator to either repair or purchase new alarms and install them. Facility to submit a picture and video to LPA of working alarms in bedroom 3 and office room. Facility to also submit a copy of receipt for purchased alarms.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2023

LIC809 (FAS) - (06/04)

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