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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601049
Report Date: 04/21/2023
Date Signed: 04/21/2023 02:11:21 PM


Document Has Been Signed on 04/21/2023 02:11 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: 4DATE:
04/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Co-Administrator, Rose Lo TIME COMPLETED:
02:20 PM
NARRATIVE
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On April 21, 2023, Licensing Program Analysts (LPAs) Komal Charitra and Grace Donato conducted an unannounced complaint visit to deliver the findings for the above allegation. 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.

During the investigation of complaint control #14-AS-20230106153247, it was indicated that Resident #1 (R1) went to the hospital on December 9, 2022 due to shortness of breathe. On 4/21/23 during the complaint investigation, LPAs asked Co-Administrator if the facility submitted a copy of the Incident Report to CCL. According to the Co-Administrator, she indicated she did not submit a report to CCL.

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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (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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Document Has Been Signed on 04/21/2023 02:11 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
04/28/2023
Section Cited
CCR
87211(a)(1)

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87211 Reporting Requirements:
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...

Violation of this regulation is evidenced by:
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Licensee/Administrator to submit acknowledgement of CCR 87211.
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Based on interviews conducted, the Co-Adminstrator indicated that an incident report was not submitted to CCL when Resident 1 (R1) was admitted to the hospital on December 9, 2022.
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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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (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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