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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601156
Report Date: 08/27/2024
Date Signed: 08/27/2024 08:50:58 PM

Document Has Been Signed on 08/27/2024 08:50 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:CEDARHILL MANOR IIFACILITY NUMBER:
415601156
ADMINISTRATOR/
DIRECTOR:		CAYABYAB, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:1117 EL CAMINO REAL, #1TELEPHONE:
(650) 242-5740
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 4CENSUS: 3DATE:
08/27/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Caregiver, Ninfa GozonTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
NARRATIVE
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On August 27, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregivers, Norma Solis and Ninfa Gozon. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including the bedrooms (2 shared rooms), 1 full- bathrooms, kitchen, common areas and 1 staff room and a storage room on the 2nd floor. 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 measured at 141 degrees F in the kitchen and it was measured at 129- 139 degrees in the bathroom (the first time was measured at 139 F and about an hour later, it was measured at 129 F).

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

A review of (3) resident files was conducted and noted on the LIC 858.
A review of (1) staff files was conducted and noted on the LIC 859.

Emergency drills were reviewed and to be adequate.

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.

LPA reviewed the P & I record.

Civil Penalty is being assess today for repeat violation.

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 caregiver. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/27/2024
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 08/27/2024 08:50 PM - It Cannot Be Edited


Created By: Murial Han On 08/27/2024 at 03:37 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 II
FACILITY NUMBER: 415601156

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024

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) (interview) (record review)], the licensee did not comply with the section cited above as hot water temperature was measured at 141 in the kitchen and 129-139 in the bathroom
which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/28/2024
Plan of Correction
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The administrator will develop a plan to ensure hot water temperature in the bathroom is within range and if it requires professional repair, the plan shall indicate what are the steps that the facility will take to ensure residents are safe. The plan shall also indicate how is the temperature going to be monitored by the administrator and/or the licensee. The administrator will submit a copy of the plan to CCL by 8/28/2024.
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 Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2024


LIC809 (FAS) - (06/04)
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