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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210054
Report Date: 10/14/2023
Date Signed: 10/14/2023 04:21:56 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/14/2023 04:21 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:CARMELINA'S HOMEFACILITY NUMBER:
419210054
ADMINISTRATOR:ALDRIN ELISEOFACILITY TYPE:
735
ADDRESS:740 PALM AVENUETELEPHONE:
(650) 989-8629
CITY:SOUTH SAN FRANCISCOSTATE: CAZIP CODE:
94080
CAPACITY: 3CENSUS: 3DATE:
10/14/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Peter BatingalTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/14/23 at 2:45pm. LPA met with Peter Batingal, Caregiver who left a message for Eliodoro Penas Jr., Administrator regarding todays visit. The caregiver is fingerprint cleared and associated to the facility.

The facility is licensed for a capacity of 3 non-ambulatory residents. LPA observed a Designation of Facility Responsibility (LIC308) for Eliodoro Penas Jr. during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. The temperature inside the facility was observed to be at 73*F which is within the required range of 68-85*F. The hot water temperature was measured at 111.4 *F which is within the required range of 105-120*F. LPA observed fire extinguisher(s), pull alarm system, smoke and carbon monoxide detectors in the facility. LPA observed the centrally stored medications area to be locked and inaccessible to residents. The first aid kit contained the required items such as sterile dressings, bandages, adhesive tape, scissors, tweezers, thermometers, antiseptic solution and guide. Staff and residents files are unavailable for review. LPA observed P&I monies for Residents are unavailable for review. LPA observed 2-day perishables and an abundance of meat items in 7-day non-perishables. However, fruit and vegetables are not present.

Upon a file review the following items were discussed to be submitted with any changes annually:
Any addendums to the Infection Control Plan, Designation of Facility Responsibility (LIC308), Personnel Report (LIC500) to include the Administrator presence in the facility, Administrator Certificate-Updated, Affidavit Regarding Client/Resident Cash Resources (LIC400), Surety Bond (LIC402), Emergency Disaster Plan (LIC610D), Administrative Organization (LIC309), Control of Property

Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights. An exit interview was conducted, a copy of the report was given.
SUPERVISORS NAME: Victoria Brown
LICENSING EVALUATOR NAME: Victoria Brown
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2023
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 10/14/2023 04:21 PM - It Cannot Be Edited


Created By: Victoria Brown On 10/14/2023 at 03:29 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: CARMELINA'S HOME
FACILITY NUMBER: 419210054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
80070(d)

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Client Records
All client records shall be available to the licensing agency to inspect...
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Licensee/Administrator shall submit in writting by fax that items will be made available for review at all times by POC due date.
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This requirement is not met as evidenced by: LPA did not observe records available for review. This poses a potential health and safety risk to residents in care.
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Type B
10/20/2023
Section Cited
CCR80066(c)

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Personnel Records
All personnel records shall be available to the licensing agency to inspect...
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Licensee/Administrator shall submit in writting by fax that items will be made available for review at all times by POC due date.
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This requirement is not met as evidenced by: LPA did not observe records available for review. This poses a potential health and safety risk to 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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/14/2023 04:21 PM - It Cannot Be Edited


Created By: Victoria Brown On 10/14/2023 at 03:41 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: CARMELINA'S HOME
FACILITY NUMBER: 419210054

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2023
Section Cited
CCR
85076(d)(1)

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Food Service
The licensee shall meet the following food supply and storage requirements:
Supplies of staple nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days shall be maintained on the premises.
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Licensee/Administrator shall submit in writting by fax that items are in facility and maintained at all times by POC due date.
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This requirement is not met as evidenced by: LPA did not observe non-perishable fruits and vegetables. This poses a potential health and safety risk to residents in care.
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Type B
10/20/2023
Section Cited
CCR80026(h)(1)

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Safeguards for Cash Resources, Personal Property, and Valuables of Residents
Each licensee shall maintain accurate records of accounts of cash resources...
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Licensee/Administrator shall submit in writting by fax that items are made available for use and/or review at all times by POC due date.
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This requirement is not met as evidenced by: LPA did not observe records to be available for review. This poses a potential health and safety risk to 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:Victoria Brown
LICENSING EVALUATOR NAME:Victoria Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2023


LIC809 (FAS) - (06/04)
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