415601061-9-23-2022-14-AS-KCHA-CJJP9G-20220923110706

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601061
Report Date: 09/23/2022
Date Signed: 09/23/2022 11:07:23 AM

Document Has Been Signed on 09/23/2022 11:07 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	GARDEN COURT AT THE VILLAGE		FACILITY NUMBER:	415601061
ADMINISTRATOR:	ALEXANDER, CARIDAD		FACILITY TYPE:	740
ADDRESS:	137 POINSETTIA AVE		TELEPHONE:	(650) 269-3974
CITY:	SAN MATEO	STATE: CA	ZIP CODE:	94403
CAPACITY:	6	CENSUS: 6	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator, Caridad Alexander		TIME COMPLETED:	11:15 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 September 23, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival LPA observed the COVID signage posted at the front entrance. LPA met with Caregiver, Rolito Cawaling and Administrator Caridad Alexander joined shortly thereafter. LPA explained the purpose of the visit. LPA was asked to sign in and fill out screening log documentation. LPA observed the screening log documentation and the visitor sign in at the front entrance. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 5 resident bedrooms, 2 full bathrooms, and an office room. LPA observed the office room. LPA toured the facility with Caregiver and observed both bathrooms to be clean and odor-free. Both bathrooms were equipped with liquid soap, paper-towels, hand-washing signs, non-skid mats, and a trash can with a fitted lid. LPA observed all 5 residents rooms of which 4 were observed to be private rooms and 1 was observed to be shared with beds 6ft apart. LPA observed Bedroom #2 door alarms, to not be working. Based on file reviewed, Resident #1 (R1) in bedroom #2, does not have dementia. Extra linen and supplies were observed to be present. LPA toured the dining room and living room to be clear from any tripping hazards. During the visit, LPA Charitra observed 4 residents in the living room watching television and maintaining social distancing. A comfortable temperature of 71 degrees F is maintained and lighting is sufficient for comfort. LPA observed the first aid kit to be completed and and medications to be locked and stored appropriately and inaccessible to residents. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable.Sharps, toxins, and chemicals were locked and stored away and inaccessible to residents. LPA toured the garage and observed chemicals and toxins to be locked. In addition, LPA observed washer and dryer to be in good repair and observed extra food supply present. Infection control practices are not observed: daily monitoring log for residents and visitors, 30-day PPE supply, and face coverings for staff. Cont. to 809C

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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: GARDEN COURT AT THE VILLAGE	FACILITY NUMBER: 415601061
	VISIT DATE: 09/23/2022

NARRATIVE

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LPA requests the following forms to be submitted to CCLD by 9/30/2022:

LIC308 Designation of Administrative Responsibility
LIC500 Personnel Report
LIC610E Emergency Disaster Plan
Administrator Certificate

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with Administrator, Cari Alexander, and a copy is provided. Appeals Rights were given.

SUPERVISOR'S NAME: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/23/2022 11:07 AM - 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: GARDEN COURT AT THE VILLAGE	FACILITY NUMBER: 415601061
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observations, facility staff failed to wear a face covering when providing care and supervision to residents. In addition, Caregiver was unable to provide LPA screening log documentation for residents and staff. Furthermore, the facility failed to ensure there was a 30-day PPE supply maintained at the facility
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Facility administrator to conduct in-service training regarding COVID-19 protocols: importance of masking, daily monitoring for staff and residents. Facility administrator to submit LPA a copy of training attendance sheet. In addition, facility administrator will buy or reach out to CCLD for more PPE to ensure a 30-day supply is present at the facility.

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: Jackie Jin	TELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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