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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 05/10/2022
Date Signed: 05/10/2022 02:31:11 PM

Document Has Been Signed on 05/10/2022 02:31 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
CCLD Regional Office, 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: 3DATE:
05/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Lead Caregiver, Ganalyn DavidTIME COMPLETED:
03:00 PM
NARRATIVE
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On 5/10/22, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20211207111332. LPA Han met with Lead Caregiver, Ganalyn and explained the purpose of the visit. LPA Han also spoke to administrator, Leslie Hui over the phone explaining the purpose of today's visit.

During the investigation of the above complaint, the administrator stated that the facility did not conduct a pre-admission appraisal prior to resident #1 (R1)'s admission. Therefore, the facility was not aware of R1's blood sugar management that was required and prescribed by R1's physician.

Based on the complaint investigation, the facility failed to preform a pre-admission on R1 to ensure R1 is suitable for the facility.

During the investigation of the above complaint, the reporting party stated that R1 was not able to administer insulin, therefore, staff #1 (S1) would be administering it for R1 but the reporting party was not sure if S1 is qualified to do that.

As part of the investigation, LPA interviewed administrator who stated that facility has a phlebotomist who is certified to administer injections would go to the facility 2x/day administering insulin injections for resident(s).

LPA interviewed resident #2 (R2) regarding to the facility's protocol on administering injections and R2 stated that S1 administered it on a daily basis as R2 was not physically capable of doing it.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105
VISIT DATE: 05/10/2022
NARRATIVE
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During the 2nd interview with administrator, the administrator confirmed that S1 was not a skilled professional nor a phlebotomist, and he/she just learned that S1 was administering injections as the phlebotomist was too busy to do it.

Based on the complaint investigation, the facility failed to ensure injections are administered by the resident or by an appropriately skilled professional.


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

Report was discussed with the administrator.

A copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/10/2022 02:31 PM - It Cannot Be Edited


Created By: Murial Han On 05/10/2022 at 12:46 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: FAMILY AFFAIR CARE HOME
FACILITY NUMBER: 415601105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/12/2022
Section Cited
CCR
87629(a)

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87629 Injections..(a) The licensee shall be permitted to accept or retain a resident who requires intramuscular,..intradermal injections if the injections are administered by the resident or by an appropriately skilled professional.
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Administrator and/or licensee will develop a plan to be in compliance with this regulation and such plan shall be submitted to CCL by 5/12/22.
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This requirement is not met as evidenced by: R2 was not able to administer injections and injections were administered by S1 who was not an appropriately skilled professional which posed an immediate health and safety risks to residents in care.
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In addition, the administrator and/or the licensee will review this regulation, and submit a statement of acknowledgment his/her review to CCL by 5/12/22.
Type A
05/12/2022
Section Cited
CCR87457(c)

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87457 Pre-Admission Appraisal - General..(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal ...
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The administrator will review this regulation and submit a written statement of compliance pertaining to the regulation to CCL by 5/12/22.

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This requirement is not met as evidenced by: the facility did not conduct a pre-admission appraisal of R1 which resulted the facility not able to meet R1's blood sugar management needs which posed an immediate health and safety risks 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:Julio Montes
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
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