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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601129
Report Date: 08/02/2023
Date Signed: 08/02/2023 12:15:12 PM


Document Has Been Signed on 08/02/2023 12:15 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: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: 13DATE:
08/02/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Loi BustamanteTIME COMPLETED:
12:25 PM
NARRATIVE
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On August 2, 2023 Licensing Program Analysts (LPA) Murial Han conducted an unannounced complaint visit in reference to complaint # 14-AS-2023726130737. LPA met with administrator and explained the purpose of the visit.

During the course of the complaint investigation, 2 facility staff stated that they were administering resident #1 (R1)'s glucose finger sticks on a daily basis and this was acknowledged by the administrator.

LPA reviewed both facility staff personnel files and observed both of them are not identified as an appropriate skilled professional.

Deficient is cited under California Health and Safety Code on the LIC 809D as the facility failed to ensure the glucose testing is performed by an appropriate skilled professional. 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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 2


Document Has Been Signed on 08/02/2023 12:15 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: JLA HEALTHCARE SERVICES LLC
FACILITY NUMBER: 415601129

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/03/2023
Section Cited
CCR
87628(a)

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87628 Diabetes..(a)The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood..or has it administered by an appropriately skilled professional.
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The licensee and/or the administrator will develop a plan to ensure compliance and the plan shall include staff education. This plan shall be submitted to CCL by 8/3/2023.
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This requirement is not met as evidenced by facility staff who are not identified as appropriate skilled professionals are administering the daily glucose finger stick checks for R1 posed an immediate health risk for 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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2