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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601111
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:47:01 PM


Document Has Been Signed on 07/23/2024 01:47 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:MANALO'S BOARD & CARE IVFACILITY NUMBER:
415601111
ADMINISTRATOR:MANALO, JOSEFINAFACILITY TYPE:
740
ADDRESS:2595 OAKMONT AVE.TELEPHONE:
(650) 868-1901
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY:8CENSUS: 8DATE:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Josefina ManaloTIME COMPLETED:
02:00 PM
NARRATIVE
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On July 23, 2024, Licensing Program Analyst (LPA), Murial Han conducted a case management visit to deliver a finding that was observed during the investigation in reference to complaint number 14- AS- 20240716163615. LPA met with the administrator and explained the purpose of today's visit.

During the investigation, LPA observed that 6 out of 8 residents did not have a completed Client/Resident Personal Property And Valuables form (LIC621) and the administrator acknowledged that the forms were either incomplete or missing and the administrator was not able to provide another form of documentation to proof that resident's personal property and valuables were recorded.

Deficient is cited under California Health and Safety Code on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and reviewed with administrator.

A copy of this report and the Appeal Rights is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 07/23/2024 01:47 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: MANALO'S BOARD & CARE IV
FACILITY NUMBER: 415601111

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/30/2024
Section Cited
CCR
87217(b)

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87217 Safeguards for Resident Cash, Personal Property, and Valuables...(b)Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
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The administrator/licensee will develop a plan to ensure compliance and will submit a copy of the plan to CCL by 7/30/2024 along with a copy of the completed LIC 621.
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The licensee shall give the residents receipts for all such articles or cash resources.. This requirement is not met as evidenced by based on observation, record review and interview, LPA observed 6 out of 8 residents did not have the LIC 621 form completed which poses a potential 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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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