<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601082
Report Date: 10/18/2023
Date Signed: 10/18/2023 02:01:03 PM


Document Has Been Signed on 10/18/2023 02:01 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:DAYTON HOME CAREFACILITY NUMBER:
415601082
ADMINISTRATOR:CALIWAG BOYER, KRIZIAFACILITY TYPE:
740
ADDRESS:1110 DAYTON AVETELEPHONE:
(650) 232-7355
CITY:SAN CARLOSSTATE: CAZIP CODE:
94070
CAPACITY:6CENSUS: 4DATE:
10/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Krizia BoyerTIME COMPLETED:
02:15 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 October 18, 2023, Licensing Program Analyst (LPA) conducted an unannounced annual inspection. LPA met with Administrator, Krizia Boyer and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, kitchen area & garage. The indoor and outdoor passageways were free of obstruction. LPA observed three residents in the living room doing exercises and one resident was observed to be sleeping. Facility was overall clean and odor-free. Comfortable temperature of 71 degrees F is maintained and lighting is sufficient for comfort.

LPA observed four private resident rooms and one staff room. Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Extra linen was present. LPA observed kitchen. Medications, toxins and sharps were observed to be locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Door alarms were observed to be in good repair.

Four resident records and three staff records were reviewed. Resident records are updated, complete and signed. During record review, LPA observed a resident who had a physician's report that indicated he/she is bedridden, however facility does not have a fire clearance to retain a bedridden resident. Staff records are complete, with training logs were observed to meet regulatory requirements. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/18/2023 02:01 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: DAYTON HOME CARE
FACILITY NUMBER: 415601082

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(c)
Care of Bedridden Residents
(c) To accept or retain a bedridden person, other than for a temporary illness or recovery from surgery, a facility shall obtain and maintain an appropriate fire clearance as specified in Section 87202(a).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, LPA observed a resident's physician's report to indicate that resident is bedridden, however facility does not have an approved fire clearance to retain a bedridden resident which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/25/2023
Plan of Correction
1
2
3
4
Facility to submit LPA a new floor plan for LPA to request a new fire clearance. During the visit, Administrator reached out to San Carlos Fire Department.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3