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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601105
Report Date: 03/20/2024
Date Signed: 03/20/2024 06:03:32 PM


Document Has Been Signed on 03/20/2024 06:03 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:10CENSUS: 8DATE:
03/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Manager, Mario AguilesTIME COMPLETED:
12:45 PM
NARRATIVE
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On 3/20/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with manager, Mario Aguiles 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.

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 room ; 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 observed extra linen present and first aid kit to be completed. LPA observed medication cabinet to be locked and inaccessible to residents in care.

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

LPA reviewed 4 resident files and 4 staff files.

Hot water temperature is measured at 105- 111 degrees F.

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 civil penalties.

This report is reviewed and discussed with administrator. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
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 3


Document Has Been Signed on 03/20/2024 06:03 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 2 out of 3 staff were not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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The administrator will provide a copy of the necessary documents to CCL by 3/21/2024 to complete the association process.
Type A
Section Cited
CCR
87412(c)
Personnel Records
(c) Licensees shall maintain in the personnel records verification of required staff training and orientation.

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 1 out of 4 staff did not have any proof that training and orientation were completed upon hire which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/21/2024
Plan of Correction
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The administrator will submit a plan to ensure all staff members have completed the required training upon hire and the plan will indicate when the staff will complete the required training. The administrator will submit a copy of the plan to CCL by 3/21/2024.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 03/20/2024 06:03 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: 03/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
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 1 out 4 staff files was not maintained at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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The administrator will submit a plan to CCL to ensure compliance by 3/27/2024.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by 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 3 out of 4 residents did not have a centrally stored medication in their file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2024
Plan of Correction
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The administrator will submit a plan to ensure compliance and will submit it to CCL by 3/27/2024. The administrator will submit a copy of the centrally stored medication record for all the residents to CCL by 3/27/2024.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/20/2024
LIC809 (FAS) - (06/04)
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