415601063-10-31-2024-14-AS-JCAA-DA4VBU-20241016161808

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601063
Report Date: 10/16/2024
Date Signed: 10/31/2024 11:07:27 AM

Document Has Been Signed on 10/31/2024 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	MISSION WOODSIDE		FACILITY NUMBER:	415601063
ADMINISTRATOR/ DIRECTOR:	GASPAR, STEPHANINE		FACILITY TYPE:	740
ADDRESS:	2028 MARYLAND STREET		TELEPHONE:	(650) 445-0510
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 2	DATE:	10/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Stephanine Gaspar, Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

NARRATIVE

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**This is an Amended Report**

On October 16, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:20 AM, to conduct the unannounced 1-year required inspection. LPA Calandra was greeted by Sylvia Sinsay, Home Health Aid and explained the purpose of the visit. Stephanine Gaspar, Administrator, Leslie Hassan-Seidman, Chief Patient Care Services, and Tatiana Barsanti, Quality Manager joined the visit later.

LPA toured the physical plant. This is a 1-story building with 6 bedrooms, 6 powder rooms/bathrooms, kitchen, living room, dining room, and back and front yards. All bedrooms had sufficient lighting and the required furniture. The bathroom had the required anti-skid floor mats and grab bars. Per interview with the Administrator, Stephanine Gaspar, the facility's fire alarms, smoke detectors, and Carbon Monoxide detectors are directly connected to the Redwood City Fire Department. Hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility's first aid kit had the required items. The facility had the required 7 days of non perishables and 2 days of perishables at the facility. No food was expired.

All sharp objects, soap, detergent, poisons, and cleaning supplies were locked up and in-accessible to persons in care.

LPA reviewed 2 resident files and 5 staff files. All were observed to be complete.

The facility does not handle cash resources at this time.

All resident medications were reflected in the Centrally Stored Medication Records kept at the facility.

LPA Calandra requested the following documents be sent to Licensing/RO by 10/23/2024:

Current Liability Insurance
Current LIC 500

LPA Calandra received the following documents at the facility:

Current Administrator Certificate for Stephanine Gaspar

Andrea Medlin	TELEPHONE: (650) 266-8811
John Calandra	TELEPHONE: 650-266-8800
	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MISSION WOODSIDE	FACILITY NUMBER: 415601063
	VISIT DATE: 10/16/2024

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During the visit on October 16, 2024, LPA Calandra observed S1 providing medications to a resident in room #3. Per interview with Administrator, Stephanine Gaspar, S1 also provides wound care, helps with breathing treatments, and assists with activities of daily living such as incontinent care. Per a review of Guardian (finger print clearance system), LPA Calandra learned that S1 did not have finger print clearance.

In the presence of the LPA, S1 was immediately dismissed from work on October 16, 2024 and will not return to work at the facility until a fingerprint clearance has been obtained per interview with Administrator, Stephanine Gaspar. The facility was assessed a Civil Penalty of $500 ($100 a day x 5 days) because LPA Calandra learned that S1 has been working at the facility from 3/14/2024 to 10/16/2024 without fingerprint clearance.

The deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties.

An exit interview was conducted. This report was reviewed with Stephanine Gaspar, Administrator and a copy of the report along with Appeal rights were sent via email on 10/31/2024.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/31/2024 11:08 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/30/2024 08:18 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: MISSION WOODSIDE	FACILITY NUMBER: 415601063
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.17(c)(1)(A)

Licensing

(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	HSC 1569.17(c)(1)(A) Licensing: This requirement is not met as evidenced by record review which showed that S1, a care provider who was observed by LPA Calandra to be providing medication to a person in care, did not have Criminal Record clearance. S1 was working at the time of the visit on 10/16/2024, which poses an immediate health, safety, or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	S1 left the facility in the presence of the LPA. The Licensee will obtain access to Guardian to ensure all staff going forward have criminal record clearance and will be associated to the facility prior to working. Furthermore, the Licensee's Human Resources(HR) department will track all on-boarding requirements and documents to ensure all staff have criminal record clearance prior to working in the facility. Deficiency cleared at time of visit on 10/31/2024.

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: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2024

LIC809 (FAS) - (06/04)

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