415601127-3-17-2023-14-AS-KCHA-CPZRKZ-20230317130621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415601127
Report Date: 03/17/2023
Date Signed: 03/17/2023 01:07:06 PM

Document Has Been Signed on 03/17/2023 01:07 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:	SERRA HIGHLANDS SENIOR LIVING		FACILITY NUMBER:	415601127
ADMINISTRATOR:	NORTH, AMANDA		FACILITY TYPE:	740
ADDRESS:	501 KING DRIVE		TELEPHONE:	(650) 878-5111
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	120	CENSUS: 58	DATE:	03/17/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Co-Administrator, Shayan Gheisar		TIME COMPLETED:	01:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On March 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Pre-Licensing visit. LPA met with Co-Administrator, Shayan Gheisar and explained the purpose of the visit. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance and LPA was screened at entry point. LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA observed the indoor and the outdoor passageways are free of obstruction. This is a two story building; with 44 resident rooms on the first floor and 51 resident rooms on the second floor. LPA observed sufficient lighting and comfortable temperature of 70-72 degrees F maintained throughout the facility. LPA toured the first floor of the facility and observed residents having lunch in the dining room. Tables were 6ft apart and residents were observed to be maintaining social distancing. LPA toured the kitchen located on the first floor and observed 2 day perishable and 7 day non-perishable. Sharps and chemicals were observed to be locked and inaccessible to residents. The kitchen door is locked at all times unless a staff member is present. Dry goods/emergency food supplies are present. LPA observed medications locked in the wellness office. Med-cart was observed to be locked and present on the first floor and the second floor. LPA observed two communal bathrooms on the first floor and two communal bathrooms on the second floor equipped with grab-bars and a pull-cords. All communal bathrooms water temperature were measured between 107-109 degrees F. LPA advised Co-administrator to ensure all communal bathrooms are equipped with a trash can with a fitted lid, hand-washing signs, and to change the soap dispenser as it was observed to not dispense soap properly. LPA observed 3 resident rooms on the first floor and 3 resident rooms on the second floor equipped with the required furniture and lighting requirements per CCLD regulations. LPA measured two resident room's water temperature and it measured at 106-107 degrees F. LPA observed the 30-day PPE supply located on the 2nd floor of the facility. LPA observed two laundry rooms on the second floor to be locked and inaccessible to residents. (CONT. TO 809C).

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (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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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: SERRA HIGHLANDS SENIOR LIVING	FACILITY NUMBER: 415601127
	VISIT DATE: 03/17/2023

NARRATIVE

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Second floor common area is currently undergoing construction. During the visit, LPA did not observe any disturbance and signs were posted.

All fire prevention systems such as sprinklers, smoke detectors, carbon monoxide detectors, fire extinguishers, and fire control panel have been inspected and approved as of 1/31/2023.

Staff room was observed on first floor to be a break room. Linen was observed to be present, however facility does not have a sufficient amount of linen for residents. According to the Administrator, per the facility contract, residents supply their own linen. Administrator will still order backup linens and provide LPA a copy of receipt.

Facility is clean and in good repair based on observations made today. Facility is in compliance with Title 22 regulations. No citations are issued. LPA is recommending licensure of the facility.

Component III is conducted and report is reviewed with Co-Administrator, Shayan Gheisar. Copy of report is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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