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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 10/24/2022
Date Signed: 10/24/2022 06:53:02 PM


Document Has Been Signed on 10/24/2022 06:53 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:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR:LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:6CENSUS: 5DATE:
10/24/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Hui (Carol) LeslieTIME COMPLETED:
07:00 PM
NARRATIVE
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In response to application for capacity increase from 6 to 10 beds, LPA Jeung inspected physical plant and observed residents. Fire clearance has been approved for 7 non-ambulatory and 3 bedridden elderly persons. Staff reside on the upper level of this 2 story home; there are 2 beds in each room. According to administrator, Ms. Leslie, staff are awake at night. There is a full bathroom on the 2nd floor for staff. On the ground level, there are 6 bedrooms and 4 bathrooms; 3 bathrooms are designated for residents and one is for staff use. Two rooms were constructed on the east side of house. A partial wall has been erected dividing the large rear bedroom on the west side of the house; there is an 8 inch open space above the wall, so the rooms are NOT fully enclosed as bedrooms, as required by San Bruno City Planning Dept.


Deficiencies of the California Code of Regulations, Title 22 are observed and cited on a following page>

The following forms are requested to be submitted to CCLD by 10/31/22:
- Personnel Report (LIC500)
- Emergency Disaster Plan (LIC610E)-- must be maintained in facility
- Bedridden Plan of Operation

Approval of capacity increase is pending receipt of the above referenced items and numbers added to client rooms. Bedrooms are not identified by number. Numbers to be added to bedroom doors for identification. The bedroom with the partial wall can be numbered and designated "A" and "B".

Ms. Leslie is advised that an emergency signal system is required if staff are NOT awake at night.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
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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Document Has Been Signed on 10/24/2022 06:53 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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2022
Section Cited

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POSTURAL SUPPORTS
Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.
This violation exists based on observation of full bed rails on bed of client #4 in
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shared room beyond living room. Client is not on hospice care. Licensee failed to ensure that full bed rails are NOT used, which poses an immediate health, safety or personal rights risk for clients in care.
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Type B
10/31/2022
Section Cited

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PERSONAL RIGHTS
Residents in all RCFEs shall have the following personal right:
To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met, as there is no COVID screening or temperature check upon
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arrival at facility for visitors. Visitor log does not include date, contact information, confirmation that COVID symptoms are absent, and temp check. Licensee failed to ensure that visitors are properly COVID screened, which poses a potential health, safety or personal rights risk to clients in care.
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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: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 10/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/24/2022
LIC809 (FAS) - (06/04)
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