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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601086
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:36:24 PM

Document Has Been Signed on 08/13/2024 04:36 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SEQUOIA HOMEFACILITY NUMBER:
415601086
ADMINISTRATOR/
DIRECTOR:		FUJII, ROGERFACILITY TYPE:
735
ADDRESS:1499 SEQUOIA AVENUETELEPHONE:
(415) 279-3128
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
08/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Administrator, Roger FujiiTIME VISIT/
INSPECTION COMPLETED:
01:00 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 August 13, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. Upon arrival, LPA was greeted by caregiver, Maritess Busa and LPA explained the purpose of today's visit. Shortly after, facility Licensed Professional, Aurora Lacsamana Academia and administrator, Roger Fujii arrived and assisted with the inspection.

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, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort.

LPA observed four private resident rooms. Rooms were spacious and included all required furnishings. Two full bathrooms were observed to be clean and in operating condition. Hot water temperature was measured at 122-124 degrees F in the kitchen and resident bathrooms. LPA observed a cautious signed posted by the faucets.

LPA observed medications, toxins and sharps to be locked and inaccessible to residents in care. 2 days for perishables and & 7 days non-perishable were observed to be present.

Emergency drill records were reviewed.

A review of (4) resident files was conducted and noted on the LIC 858.
A review of (3) staff files was conducted and noted on the LIC 859.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2024
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 08/13/2024 04:36 PM - It Cannot Be Edited


Created By: Murial Han On 08/13/2024 at 12:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIA HOME
FACILITY NUMBER: 415601086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as resident bathroom hot water temperature was measured at 122-124 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
1
2
3
4
The administrator will provide a plan of the steps that the facility is performing at this time in dealing with the hot water temperture and will provide a plan to ensure resident's safety before the hot water temperature is fixed and within normal range. The administrator will provide a copy of the plan to CCL by 8/14/2024.
Type A
Section Cited
CCR
80069(b)
Client Medical Assessments
(b) In ARFs, prior to accepting a client into care, the licensee shall obtain and keep on file documentation of the client's medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 4 residents did not have a Physician's Order (LIC602) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure all residents have a Physician's Order (LIC602) completed prior to admission. The administrator will provide a copy of the plan to CCL by 8/14/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/13/2024 04:36 PM - It Cannot Be Edited


Created By: Murial Han On 08/13/2024 at 12:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIA HOME
FACILITY NUMBER: 415601086

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80069(c)(1)
Client Medical Assessments
(c) The medical assessment shall include the following: (1) The results of an examination for communicable tuberculosis and other contagious/infectious diseases.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 1 out of 4 residents did not have documentation of TB results which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
1
2
3
4
The administrator will develop a plan to ensure all residents have documenation of TB results as part of the Physician's Order prior to admission, The administrator will provide a copy of the plan to CCL by 8/14/2024.
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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024


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