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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 03/17/2023
Date Signed: 03/17/2023 10:50:15 AM


Document Has Been Signed on 03/17/2023 10:50 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: 5DATE:
03/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Leslie HuiTIME COMPLETED:
11:00 AM
NARRATIVE
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On March 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced conducted an unannounced case management visit in relation to complaint control #: 14-AS-20230216132540. LPA met with Administrator, Leslie Hui and explained the purpose of the visit.

During the investigation of complaint control #14-AS-20230216132540, it was indicated that Resident #1 (R1) went to the hospital on 2/15/23 for pneumonia. On 2/21/23, during a complaint investigation, LPA asked Administrator if she submitted a copy of the Incident Report to CCL. According to the Administrator, she indicated she was unaware that an Incident Report needed to be submitted to CCL.

During the same complaint investigation, it was indicated that the Co-Administrator, Xuefei Huang told R1 to lie about his/her symptoms to be taken to the hospital. When LPA addressed this to the Administrator and Co-Administrator, and she denied this statement and indicated that R1 was experiencing symptoms.

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.

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: 03/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
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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Document Has Been Signed on 03/17/2023 10:50 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: 03/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/24/2023
Section Cited

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87211 Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below...

Violation of this regulation is evidenced by:
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Facility administrator to read CCR 87211 Reporting Requirements and submit acknowledgement of the regulation to LPA by due date.
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Based on the interviews conducted an information collected, the facility failed to submit an incident report for an incident that occurred on 2/15/23. In addition the facility adminsitrator acknowledged that she was unaware that a report had to be submitted to CCL.
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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: 03/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/17/2023
LIC809 (FAS) - (06/04)
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