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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210045
Report Date: 05/08/2024
Date Signed: 05/08/2024 12:16:29 PM

Document Has Been Signed on 05/08/2024 12:16 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:LOLA'S HOMEFACILITY NUMBER:
419210045
ADMINISTRATOR/
DIRECTOR:		ADAM CANONFACILITY TYPE:
735
ADDRESS:2956 FLEETWOOD DRIVETELEPHONE:
(650) 873-3530
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
05/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:01 PM
MET WITH:House Manager, Joyce CangcangTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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On 5/8/2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow up on an incident that was reported by the facility. LPA met with house manager, Joyce and explained the purpose of today's visit.

On 11/20/2023, the facility reported to Community Care Licensing (CCL) that on 11/13/2023, the facility staff noted some bruises on resident #1 (R1)'s body and they were getting worse as well as new bruises were noted. The facility also reported that the bruises appeared to be caused by punches, kicks, and pinches.

Based on the documents provided, on 11/10/2023, R1's day program reported there was no bruises or incidents that had happened and there were no bruises reported by the facility on 11/11/2023 at the facility. R1 was taken for lab work and the results were normal.

During the initial interview with facility staff, staff #1 (S1) reported that he/she suspected staff #2(S2) abused R1 as S2 was the only staff working the night shift and on 11/12/2023, S1 reported that he/she heard S2 yelling at R1 in the room and witnessed S2 slapping R1.

After the investigation, this incident has been substantiated.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed and reviewed with the house manager.

A copy of this report and the Appeal Rights is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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 05/08/2024 12:16 PM - It Cannot Be Edited


Created By: Murial Han On 05/08/2024 at 12:03 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: LOLA'S HOME
FACILITY NUMBER: 419210045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
80072(a)(3)

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80072 Personal Rights..(3) To be free from corporal or unusual punishment, infliction of pain,... This requirement is not met as evidenced by: based on interviews, record review and
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The administrator/licensee will develop a plan to ensure this does not happen again and the plan shall include staff in-services. The administrator/licensee will provide a copy of the signed and dated plan
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interviews, S1 reported witnessing S2 hitting R1 which poses an immediate health risks to residents in care.
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to CCL by 5/9/2024.

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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: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/08/2024


LIC809 (FAS) - (06/04)
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