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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 02/21/2023
Date Signed: 02/21/2023 11:22:01 AM


Document Has Been Signed on 02/21/2023 11:22 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: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:10CENSUS: 4DATE:
02/21/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Leslie HiuTIME COMPLETED:
11:30 AM
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On February 21, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Caregiver, Genalyn David and Administrator, Hui Leslie joined shortly thereafter. LPA explained the purpose of the visit. Upon arrival, LPA observed the COVID signage posted at the front entrance. LPA was screened at entry point and Caregiver was able to provide screening log documentation for visitors, residents and staff.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a double story home. LPA toured the first floor and observed 7 resident bedrooms; two of which are shared rooms with beds 6ft apart. LPA observed 3 full bathrooms and 2 half bathrooms. Bathrooms were equipped with liquid soap, paper towels and a trash can with a fitted lid. LPA advised caregiver to remove bar soaps from communal bathrooms. LPA observed extra linen present and first aid kit to be completed. LPA observed medication cabinet to be unlocked and accessible to residents. Caregiver locked the medication cabinet in LPA's presence.

LPA observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. Overall the facility is odor-free and in good repair. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable, however LPA observed facility fridge to have expired milk. Sharps drawer was observed to be locked, however LPA observed a knife on the kitchen counter-top and no staff present. Expired milk was thrown away during the visit and caregiver put the knife in the locked cabinet.

LPA toured the garage and observed chemicals and toxins cabinet to be unlocked. Cabinet was immediately locked by caregiver. In addition, LPA observed washer and dryer to be in good working condition and observed extra food supply present. 30-day PPE supply was present. (CONT. TO 809C)
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 02/21/2023
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During the visit, LPA observed Staff 1 (S1) to not be fingerprint cleared and/or associated to the facility. According to the administrator, S1 will be going to get fingerprinted today. LPA toured second floor and observed 2 caregiver rooms and a full bathroom to be clean.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

LPA requests the following forms to be submitted to CCLD by 2/28/23:
-LIC308 Designation of Administrator Organization
-LIC500 Personnel Report
-LIC610D Emergency Disaster Plan
-Administrator Certificate

Report is reviewed with Administrator and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/21/2023 11:22 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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2023
Section Cited

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87355 Criminal Record Clearance:(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department or...

Violation of this regulation is not met as evidenced by:
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Facility will not have S1 work at the facility till he is fingerprinted AND associated to the facility. Facility administrator to provide LPA documentation of fingerprint status by 2/22/23.
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During the visit, LPA observed S1 cleaning the facility however he was not fingerprint cleared and/or associated. In addition, Administrator indicated that S1 has an appointment to get fingerprinted on 2/21/23.
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Type A
02/22/2023
Section Cited

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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees...

Violation of this regulation is not met as evidenced by:
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Facility caregiver immediately locked the medication cabinet in LPA's presence. Administrator to conduct and in-service training regarding the importance of locking medication.
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During the visit, LPA observed the medication cabinet to be unlocked and accessible which poses an immediate health and safety concern to residents 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: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 02/21/2023 11:22 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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/22/2023
Section Cited

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87309 Storage Space: (a) Disinfectants, cleaning solutions, poisons...which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

Violation of this regulation is not met as evidenced by:
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Facility caregiver immediately locked the chemical and toxins cabinet in LPA's presence. Administrator to conduct and in-service training regarding the importance of locking chemicals and toxins.
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During the visit, LPA observed the chemicals and toxins cabinet located in the garage to be unlocked and inaccessible to residents which poses an immediate health and safety risk to residents in care.
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Type A
02/22/2023
Section Cited

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87705 Care of Persons with Dementia: (f) The following shall be stored inaccessible to residents with dementia: (1) Knives... and other items that could constitute a danger to the resident(s).

Violation of this regulation is not met as evidenced by:
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Facility caregiver immediately locked the knife in LPA's presence. Administrator to conduct and in-service training regarding the importance of locking sharps.
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During the visit, although LPA observed the knives locked and stored away from residents, LPA observed a knife on the kitchen counter top while a staff member was not present
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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: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 02/21/2023 11:22 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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2023
Section Cited

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87555 General Food Service Requirements: (b) The following food service requirements shall apply: (8) All food shall be of good quality...

Violation of this regulation is not met as evidenced by:
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Administrator threw out all the expired milk during the visit. Administrator to provide a picture of the receipt after grocery shopping
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During the visit, LPA observed the facility fridge to have gallons of expired milk which poses an immediate health and safety risk to residents 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: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5