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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601156
Report Date: 12/28/2023
Date Signed: 12/28/2023 04:26:22 PM

Document Has Been Signed on 12/28/2023 04:26 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 MANOR IIFACILITY NUMBER:
415601156
ADMINISTRATOR:CAYABYAB, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:1117 EL CAMINO REAL, #1TELEPHONE:
(650) 242-5740
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 1DATE:
12/28/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Caregiver, Norma SolisTIME COMPLETED:
12:10 PM
NARRATIVE
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On 12/28/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced post licensing inspection. LPA was greeted by caregiver, Norma Solis. LPA explained the purpose of the visit.

After LPA toured the facility with the caregiver, administrator, Christopher Cayabyab arrived and assisted with the rest of the inspection.

LPA toured the facility inside and outside including the bedrooms (2 shared rooms), 1 full- bathrooms, 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 was measured at 130-137 degrees F.

During the tour of the facility, LPA did not observed adequate outdoor area/space for residents. This observation was shared with the administrator and possible plan of correction was discussed.

Central stored medication, toxins and sharps objects were locked and inaccessible to residents.

LPA reviewed 1 resident record and it contained admission agreement, medical assessment- LIC 602 (Physician Order), Appraisal Needs and Service Plan Resident Identification information, Pre-appraisal assessment, etc.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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 12/28/2023 04:26 PM - It Cannot Be Edited


Created By: Murial Han On 12/28/2023 at 11:34 AM
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 II
FACILITY NUMBER: 415601156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview, the licensee did not comply with the section cited above as the hot water temperature in the kitchen and bathroom sinks were measured at 130-137 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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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 12/29/2023.
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

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 for the kitchen and bathroom sinks were above 125 degrees F and there was no warning signs posted which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2023
Plan of Correction
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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 12/29/2023.
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: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 12/28/2023 04:26 PM - It Cannot Be Edited


Created By: Murial Han On 12/28/2023 at 11:34 AM
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 II
FACILITY NUMBER: 415601156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(h)(2)
Planned Activities
(h) Facilities shall provide sufficient space to accommodate both indoor and outdoor activities. Activities shall be encouraged by provision of: (2) Outdoor activity areas which are easily accessible to residents and protected from traffic. Gardens or yards shall be sufficient in size, comfortable, and appropriately equipped for outdoor use.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, and interview the licensee did not comply with the section cited above as the facility does not have an adequate outdoor space for resident(s) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/04/2024
Plan of Correction
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LPA discussed with the administrator the potential outdoor space at the facility that the residents could utilize. When the potential outdoor space is set up for residents to use, the administrator will provide photos of the location and will provide a copy of the plan to ensure resident's safety by 1/4/2024.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


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: CEDARHILL MANOR II
FACILITY NUMBER: 415601156
VISIT DATE: 12/28/2023
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LPA reviewed 1 staff file and it contained personnel records, Health Screening Report, Abuse Statement, First Aide/CPR, Criminal Record Statement, fingerprint cleared, etc.

Food supplies were observed to be adequate.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguishers were last serviced on 11/7/2023. Disaster drills records were reviewed.

LPA reviewed the P & I records and observed Record of Client's/ Resident's Safeguarded Case Resources (LIC 405) and receipts for 1 resident.

During today's inspection, there are no resident present as the resident is attending the adult 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 the administrator. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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