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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 03/18/2025
Date Signed: 03/18/2025 06:27:19 PM

Document Has Been Signed on 03/18/2025 06:27 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:FAMILY AFFAIR CARE HOMEFACILITY NUMBER:
415601105
ADMINISTRATOR/
DIRECTOR:		LESLIE, HUI C.FACILITY TYPE:
740
ADDRESS:3100 COLLEGE DR.TELEPHONE:
(650) 871-5095
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 10CENSUS: 10DATE:
03/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator, Hui Carol LeslieTIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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On 3/18/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with caregivers Marcelo Sumalnap ad Thelma Olson and explained the purpose of the visit. The administrator Hui C. Leslie and the assistant administrator, Xue F Huang arrived shortly thereafter to assist with the annual inspection.

Upon entry, LPA observed S3 and S4 were working and based on record review, both of them did not have a criminal background clearance. LPA informed the administrator to remove S3 and S4 immediately.

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 rooms of which 3 share rooms and 4 private rooms. 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 observed extra linen.

During today's visit, LPA observed garage was cluttered, uncleaned cat food all over the ground, files, dirty plastic bags on the floor, table, unknown brown liquid bottle on the table, lighter, cigarettes on top of the laundry, and soiled linens on the floor.

LPA reviewed 4 staff files.

Civil penalty of the following in being assessed today in the amount of $2000:

- $500 x2 for Criminal Background Clearance
- $250 x2 for repeat violations that were identified from the annual visit on March 20, 2024: 87412(a) and 87355(e)(4)
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2025
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 5
Document Has Been Signed on 03/18/2025 06:27 PM - It Cannot Be Edited


Created By: Murial Han On 03/18/2025 at 09:58 AM
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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)(4)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S3 and S4 did not have any documents in their files to verify this information which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.
Type A
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as 4 out of 4 staff did not have proof that their health screen was completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.
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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2025 06:27 PM - It Cannot Be Edited


Created By: Murial Han On 03/18/2025 at 10:09 AM
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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S1 and S2 have missing documents from the personnel records and S3 and S4 did not have a personnel file which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.
Type A
Section Cited
CCR
87355(e)(4)
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: (4) Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as S3 and S4 did not have proof that background/fingerprint clearance process were completed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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The administrator will develop a plan in writing to ensure compliance and the plan shall indicate the compliance date no later than 3/25/2025. The administrator will provide a copy of the plan of correction to CCL by 3/19/2024.
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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/18/2025 06:27 PM - It Cannot Be Edited


Created By: Murial Han On 03/18/2025 at 10:21 AM
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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)


This requirement is not met as evidenced by: 87202 Fire Clearance

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department,
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as the facility converted a private room (bedroom 3) into a 2 bedroom without a fire clearance was which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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The administrator will develop a plan to ensure compliance and the compliance date should be no later than 3/25/2025. The administrator will submit a copy of the plan to CCL by 3/19/2025.
Type A
Section Cited
CCR
87303(a)


This requirement is not met as evidenced by: 87303 Maintenance and Operation



(a) The facility shall be clean, safe, sanitary and in good repair at all times.
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed garage was cluttered, uncleaned cat food all over the ground, files, dirty plastic bags on the floor, table, unknown brown liquid bottle on the table, lighter, cigarettes on top of the laundry, and soiled linens on the floor which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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The administrator will develop a plan to ensure the facility is clean and safe at all times and will submit a copy of the plan of correction to CCL by 3/19/2025.
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: 03/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2025


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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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 03/18/2025
NARRATIVE
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LPA will return on another day to complete the inspection.

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 additional 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: 03/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2025
LIC809 (FAS) - (06/04)
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