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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 06/17/2024
Date Signed: 06/18/2024 01:53:13 PM


Document Has Been Signed on 06/18/2024 01:53 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:JLA HEALTHCARE SERVICES LLCFACILITY NUMBER:
415601129
ADMINISTRATOR:LEONARD, JEROMEFACILITY TYPE:
740
ADDRESS:1185 ACACIA STREETTELEPHONE:
(650) 477-2857
CITY:MONTARASTATE: CAZIP CODE:
94037
CAPACITY:24CENSUS: 17DATE:
06/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Eloisa BustamanteTIME COMPLETED:
01:15 PM
NARRATIVE
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On June 17, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA was met with the administrator, Loi Bustamante and LPA explained the purpose of the visit.

LPA toured the facility inside out and inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. A tour of resident's room was conducted and observed to have sufficient furniture and furnishings. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort.
Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time. Residents observed to have a call pendant for assistance,
Central storage for medications, sharps and chemicals were observed to be locked and inaccessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 108-117 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 4/22/2024.

A review of (5) resident files was conducted and noted on the LIC 858.
A review of (5) staff files was conducted and noted on the LIC 859.

The following documents were requested submitted to CCL by 6/24/24:
- Control of Property, LIC 500, Liability Insurance, Administrator Certification

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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
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 06/18/2024 01:53 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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.695(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 residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and 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) (interview) (record review)], the licensee did not comply with the section cited above as facility was not able to provide documents to proof that emergency drills were conducted accordingly which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide an in-service on drills. The administrator will provide a copy of the plan and staff in-service record to CCL by 6/18/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 01:53 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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 LPA observed 1 staff did not have records to proof that required training was completed which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan and training records to CCL by 6/24/2024.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

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 resident's admission agreement was blank and not signed by the resident and/ the responsible party which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan and the completed admission agreement to CCL by 6/24/2024.
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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 01:53 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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87456(a)(3)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (3) Obtain and evaluate a recent medical assessment.

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 LPA observed 1 resident did not have a copy of the medical/physician's assessment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the plan and a copy of the physician's order to CCL by 6/24/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 01:53 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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(d)(f)


This requirement is not met as evidenced by: 87411 Personnel Requirements - General
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 4 out of 5 staff's personnel files did not have health screening and 2 out of 5 staff did not have TB records which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and the plan shall indicate when the health screening/TB will be completed for the 4 out of 5 staff members. The administrator will provide a copy of the signed and dated plan to CCL by 6/18/2024.
Type A
Section Cited
CCR
87608(a)(3)


This requirement is not met as evidenced by:87608 Postural Supports
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed 4 out of 5 residents have half bedrails installed on their bed and the facility was not able to provide a copy of the physician's order for such device which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/18/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and on the plan, it shall indicate when a physician's order will be obtained. The administrator will provide a copy of the signed and dated plan of correction to CCL by 6/18/2024.
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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 06/18/2024 01:53 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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/17/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)


This requirement is not met as evidenced by: ยง1569.69 Employees assisting residents with self-administration of medication; training requirements
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as LPA observed a caregiver/med tech's training record was expired on 6/5/2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/24/2024
Plan of Correction
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The administrator will develop a plan to ensure compliance and will provide a copy of the signed and dated plan to CCL by 6/24/2024 and a copy of the training record.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 06/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/17/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6