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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601121
Report Date: 12/13/2023
Date Signed: 12/13/2023 05:53:44 PM

Document Has Been Signed on 12/13/2023 05:53 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:CEDARHILL MANORFACILITY NUMBER:
415601121
ADMINISTRATOR:FORONDA-CAYABYAB, MARIE JAFACILITY TYPE:
735
ADDRESS:1117 EL CAMINO REAL #2TELEPHONE:
(510) 915-0629
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 4DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Caregiver, Arlene Oliver TIME COMPLETED:
01:50 PM
NARRATIVE
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On December 13, 2023 Licensing Program Analyst(LPA) Murial Han and LPA John Calandra conducted an unannounced annual inspection. LPAs met with caregiver, Arlene Oliver and explained the purpose of today's visit. The administrator arrived and assisted with the rest of the inspection.

LPAs toured the facility inside and outside including the 2 shared bedrooms, 1 full- bathroom, kitchen, and common areas. The facility observed to clean, tidy and in good repair. Bedrooms were equipped with the required furniture for residents to use. Bathroom is equipped with grab bars, and nonskid mats. Facility temperature is comfortable. Hot water temperature in the bathroom and the kitchen were measured at 140- 148 degrees F.

Central stored medication observed to be locked and inaccessible to residents in care.

Chemicals and sharp object reviewed and observed.

Staff files contain personnel records, health screening, Abuse Statement, First Aide and CPR, Criminal Record Statement, training records, etc.

Resident records were reviewed and contain medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP except for 1 out of 4 residents (resident #3) did not have a facility and GGRC admission agreement.

LPAs reviewed the P & I records and observed Record of Client's/ Resident's Safeguarded Case Resources (LIC 405) and receipts for 2 residents to be adequate.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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 4
Document Has Been Signed on 12/13/2023 05:53 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Murial Han On 12/13/2023 at 01:15 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: CEDARHILL MANOR
FACILITY NUMBER: 415601121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80088(e)(1)
Fixtures, Furniture, Equipment, and Supplies
(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the hot water temperature in the bathroom and the kitchen was measured at 140- 148 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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The administrator/licensee will turn down the hot water heater immediately and have the hot water measured on a daily basis for a period of 7-days. A statement of correction will be provided to CCL by 12/14/2023, and a copy of the week long reading will be provided on 12/22/2023.
Under Appeal
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview the licensee did not comply with the section cited above as one of R2's medication was prescribed by the physician as daily, however, the medication administration record stated PRN which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2023
Plan of Correction
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The administrator/Licensee will contact the physician and clarify the order accordingly. The administrator/licensee will provide a copy of the clarification order to CCL by 12/14/2023.
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 Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/13/2023 05:53 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Murial Han On 12/13/2023 at 01:15 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: CEDARHILL MANOR
FACILITY NUMBER: 415601121

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
80068(a)(1)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any. (1) Prior to admitting a developmentally disabled adult recommended by a Regional Center, the licensee of an ARF shall obtain from the Regional Center written certification which states that there was no objection to the placement by any persons specified in Welfare and Institutions Code Section 4803.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review the licensee did not comply with the section cited above as R3's admission agreement was incomplete and R3 was admitted on 12/12/2023 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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The administrator/licensee will provide a statement to ensure compliance and will provide a copy of R3's complete GGRC and facility agreement to CCL by 12/20/2023.
Type B
Section Cited
HSC
1565(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview the licensee did not comply with the section cited above as the facility's disaster drills were not completed at least every quarter every shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/20/2023
Plan of Correction
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The administrator/licensee will develop a plan to ensure drills are completed at least every quarter, every shift. The administrator/licensee will provide a copy of the plan to CCL by 12/20/2023.
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 Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023


LIC809 (FAS) - (06/04)
Page: 3 of 4
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: CEDARHILL MANOR
FACILITY NUMBER: 415601121
VISIT DATE: 12/13/2023
NARRATIVE
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During today's inspection, there were no residents present as they were attending the day program.

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.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4