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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210022
Report Date: 06/01/2023
Date Signed: 06/02/2023 01:00:43 PM

Document Has Been Signed on 06/02/2023 01:00 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:CHOICE MANOR IFACILITY NUMBER:
419210022
ADMINISTRATOR:MYRON X BOLDENFACILITY TYPE:
735
ADDRESS:531 EDGEMAR AVE.TELEPHONE:
(650) 355-8532
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 6CENSUS: 6DATE:
06/01/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Caregiver, Maribel VegaTIME COMPLETED:
01:15 PM
NARRATIVE
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On 6/1/2023, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by caregiver, Maribel Vega. LPA explained the purpose of the visit. Ms. Vega called administrator, Myron Bolden who arrived later to assisted with the inspection.

Ms. Vega provided a tour of the facility and LPA observed the 4 bedrooms (2 private rooms and 2 shared rooms), 2 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. Bathrooms are equipped with grab bars, and nonskid mats. Facility has recently installed the digital and key locks on each resident's doors to promote privacy. Facility temperature is comfortable at 72 degrees F. Hot water temperature was measured at 106- 110 degrees F.

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

Staff files and training records were reviewed; food supplies were observed to be adequate.

Based on the emergency drill records, it revealed that the latest ones were completed on July 15, 2021 and April 29, 2023.

Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher was last serviced July 2, 2021.

Staff members at the facility were fingerprint cleared and associated to the facility.

LPAs reviewed resident records that contain admission agreement, medical assessment, LIC 602 (Physician Order), Appraisal Needs and Service Plan, GGRC/IPP.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/01/2023
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 5
Document Has Been Signed on 06/02/2023 01:00 PM - It Cannot Be Edited


Created By: Murial Han On 06/01/2023 at 12:04 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: CHOICE MANOR I
FACILITY NUMBER: 419210022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1565(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 individuals served by the facility is not required during a drill. While a facility may provide an opportunity for individuals served by the facility to participate in a drill, it shall not require that participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and, if applicable, 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 and record review, the facility failed to complete the drills at least quarterly per shift the licensee did not comply with the section cited above in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/02/2023
Plan of Correction
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The administrator will develop a plan to ensure compliance. A copy of this plan shall be submitted to CCL by 6/02/23.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 06/02/2023 01:00 PM - It Cannot Be Edited


Created By: Murial Han On 06/01/2023 at 12:04 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: CHOICE MANOR I
FACILITY NUMBER: 419210022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80066(a)(12)(B)1
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (12) For employees that are required to be fingerprinted pursuant to Section 80019: (B) Documentation of either a criminal record clearance or exemption as required by Section 80019(e). 1. For Certified Administrators, a copy of their current and valid Administrator Certification meets this requirement.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, LPA observed the administrator certification has expired in June 2022; the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee/administrator will develop a plan to ensure compliance. A copy of this plan will be submitted to CCL by 6/14/2023.
Type B
Section Cited
CCR
80092.1(l)
General Requirements for Restricted Health Conditions
(l) All training shall be documented in the facility personnel files.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, staff #1 did not any training records indicating that S1 was provided required training; the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The administrator will provide required training to S2 and provide a copy of the training records to CCL by 6/14/2023.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 06/02/2023 01:00 PM - It Cannot Be Edited


Created By: Murial Han On 06/01/2023 at 12:04 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: CHOICE MANOR I
FACILITY NUMBER: 419210022

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85092.7(b)(2)
Staph or Other Serious, Communicable Infections
(b) If the licensed health professional delegates routine care, the following requirements must be met for the health conditions specified in subsection 85092.7(a):  (2) The licensee ensures that the licensed professional reviews staff performance as often as necessary, but at least annually. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record reviews, 2 out of 2 staff did not have documents to show that their annual performance was conducted; the licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee/administrator will develop a plan to ensure compliance. A copy of this plan will be submitted to CCL by 6/14/2023.
Type B
Section Cited
HSC
1565(b)
Other Provisions
(b) If a facility employs staff, the facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record reviews and interviews, 2 out of 2 staff files did not have documents to show that they have completed the emergency disaster training. The licensee did not comply with the section cited above in which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2023
Plan of Correction
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The licensee/administrator will develop a plan to ensure compliance. A copy of this plan will be submitted to CCL by 6/14/2023.
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: 06/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023


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: CHOICE MANOR I
FACILITY NUMBER: 419210022
VISIT DATE: 06/01/2023
NARRATIVE
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LPAs reviewed the P & I records and observed Record of Client's/ Resident's Safeguarded Case Resources (LIC 405) and receipts for 2 clients.

During today's inspection, there were no residents present as they were attending the adult day program.

The following deficiencies are observed during today's inspections: facility was not able provide documentation of completion on Emergency Drills, training records for staff #1 (S1), annual performance evaluation for S1 and staff #2 (S2) and disaster training records for S1 and S2. In addition, LPA observed administrator certification expired in 2022 and facility did not have a current copy.

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 Appeal Rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2023
LIC809 (FAS) - (06/04)
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