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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210071
Report Date: 11/05/2024
Date Signed: 11/05/2024 06:23:28 PM

Document Has Been Signed on 11/05/2024 06:23 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:NORCAL CARE HOMES, INC.FACILITY NUMBER:
419210071
ADMINISTRATOR/
DIRECTOR:		ANGELA N STA MARIAFACILITY TYPE:
735
ADDRESS:460 BODEGA STREETTELEPHONE:
(650) 377-2530
CITY:FOSTER CITYSTATE: CAZIP CODE:
94404
CAPACITY: 3CENSUS: 3DATE:
11/05/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Administrator, Angela Sta MariaTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On November 5, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual visit. Upon arrival, LPA met with Administrator, Angela Sta Maria and caregiver, Russlyn Guevarra. LPA explained the purpose of today's visit. The Licensee arrived shortly thereafter.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 3 resident bedrooms, 2 full bathrooms, and an office room. LPA toured the facility with the administrator and observed living room and dining room to be clean and free from any tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. During the visit, there was 1 resident present. According to the administrator, the other 2 residents were at their day program.

Bathrooms observed clean and in operating condition. Showers were observed equipped with non-skid mats and grab bars. LPA observed the cover of the toilet tank in one of the bathrooms was cracked and according to administrator, this happened a few months ago where the cover fell onto the floor and cracked it; according to the licensee, the facility has been working with the property owner to get it fixed and as of today, there is no update as to when it will be fixed or replaced.

Facility exits are equipped with audible alarms; extra linens present.

LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable.

LPA toured the garage and observed chemicals and toxins to be locked and inaccessible to residents in care. The garage also stored emergency supples.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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 11/05/2024 06:23 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Murial Han On 11/05/2024 at 01:12 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: NORCAL CARE HOMES, INC.
FACILITY NUMBER: 419210071

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Under Appeal
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

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 LPA observed the cover to the toilet tank in one of the bathrooms was cracked which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/13/2024
Plan of Correction
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The administrator/licensee will provide a plan in writing indicating what the facility will do to ensure resident's safety and on the plan, it shall indicate the date that the tank cover would be fixed or replaced. The administrator/licensee will provide a copy of the plan to CCL by 11/13/2024.
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: 11/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/05/2024


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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: NORCAL CARE HOMES, INC.
FACILITY NUMBER: 419210071
VISIT DATE: 11/05/2024
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Central storage for medications, and sharps were observed to be locked and inaccessible to residents in care.

Hot water temperature in the kitchen and bathroom were measured at 106-117 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 5/13/2024.

A review of (3) resident files was conducted and noted on the LIC 858.
A review of (2) staff files was conducted and noted on the LIC 859.

P & I were reviewed for 2 residents to be accurate.

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 and licensee. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2024
LIC809 (FAS) - (06/04)
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