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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210087
Report Date: 10/09/2023
Date Signed: 10/29/2024 12:04:03 PM

Document Has Been Signed on 10/29/2024 12:04 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:FLORA'S HOMEFACILITY NUMBER:
419210087
ADMINISTRATOR:ANCHETA, KELLYFACILITY TYPE:
735
ADDRESS:1008 CORTEZ AVENUETELEPHONE:
(650) 315-2242
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
10/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Arvin MarianoTIME COMPLETED:
07:00 PM
NARRATIVE
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This is an Amended report from an Original dated October 9, 2023**

Licensing Program Analyst (LPA) Victoria Brown arrived unannounced to conduct a Required - 1 Year visit on 10/9/23 at 4:20pm. LPA met with Arvin Mariano, House Manager/Caregiver and stated the purpose of the visit. The caregiver is fingerprint cleared and associated to the facility. Adora Ancheta, Licensee arrived within 15 minutes to assist with todays visit. The facility is licensed for a capacity of 6 residents of which 4 maybe non-ambulatory. LPA observed a Designation of Facility Responsibility (LIC308) for Arvin Mariano during this visit. The Administrator Certificate was observed for Kelly Ancheta which expired 5/18/23. LPA did not observe documentation of payment and hours for renewal. LPA observed P&I monies for Resident #1 (R1) which has been documented at $594.88 monies to be present. However, LPA and Arvin Mariano, House Manager/Caregiver counted the monies being held as 609.88 which is not commingled but not documented properly during this visit. LPA observed residents participating in group activities during this visit. LPA toured and inspected the physical plant inside and outside to ensure there are no safety hazards to residents. LPA observed 2-day perishables and 7-day non-perishables. The temperature inside the facility was observed to be at 71*F which is within the required range of 68-85*F. The hot water temperature was measured at 139.4 *F which is not 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. LPA observed 2 staff files and 2 resident files and conducted interviews of staff during this visit.

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 (LIC610E), Administrative Organization (LIC309), Control of Property

Per California Code of Regulations (CCRs) - Title 22, Division 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: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/09/2023
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 3
Document Has Been Signed on 10/29/2024 12:04 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/28/2024 04:51 PM


Created By: Murial Han On 10/09/2023 at 05:08 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FLORA'S HOME
FACILITY NUMBER: 419210087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2023
Section Cited

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85064.3 Administrator Recertification Requirements(a) Administrators shall complete at least forty (40) classroom hours of continuing education during each two-year certification period, including:.. (1) At least four (4) hours of instruction in laws, regulations, policies, and..(2) If not included in the certified administrator's Initial Certification Training Program, at least one (1) hour of instruction..
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This requirement is not met as evidenced by: LPA did not observe a renewed adm cert Based on confirmation from Licensee the certificate has not been renewed and not paid for.
This poses an immediate health and safety risk to residents in care.
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Type A
10/10/2023
Section Cited

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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents...(h) Each licensee shall maintain accurate records of accounts of cash resources,...(1) Records of clients' cash resources maintained as a drawing account, which shall include a current ledger accounting,


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This requirement is not met as evidenced by: LPA observed more money in residents cash account. Based on counting the monies there is more money than it should be.
This poses an immediate 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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 10/29/2024 12:04 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 10/28/2024 04:24 PM


Created By: Murial Han On 10/09/2023 at 05:43 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: FLORA'S HOME
FACILITY NUMBER: 419210087

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/10/2023
Section Cited

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80088 Furniture, Fixtures, Equipment, and Supplies..(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water.(1) Hot water temperature controls shall be maintained... not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C).

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This requirement is not met as evidenced by: LPA measured the hot water at 139.4 *F Based on meaurement of the hot water during this visit. This poses an immediate 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:April Cowan
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 10/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/09/2023


LIC809 (FAS) - (06/04)
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