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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210094
Report Date: 05/09/2024
Date Signed: 05/14/2024 08:25:45 AM

Document Has Been Signed on 05/14/2024 08:25 AM - 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:HILLSBOROUGH MANORFACILITY NUMBER:
419210094
ADMINISTRATOR/
DIRECTOR:		ROSEMARIE VERDIANOFACILITY TYPE:
735
ADDRESS:515 DARRELL ROADTELEPHONE:
(650) 340-9401
CITY:HILLSBOROUGHSTATE: CAZIP CODE:
94010
CAPACITY: 6CENSUS: 6DATE:
05/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator, Rosemarie VerdianoTIME VISIT/
INSPECTION COMPLETED:
12:40 PM
NARRATIVE
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On May 9, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with administrator, Rosemarie Verdiano and Program Coordinator, Rommel Dionson. LPA explained the purpose of today's visit.

LPA toured the facility inside and out. There are 1 shared bedroom and four private bedrooms for residents and 2 common bathrooms plus a private bathroom in room 3. In the garage, there is a small staff room with 2 bunk beds in it, and adjacent bathroom. On the lower level, there is a living unit for staff, with 3 bedrooms, 2 storage rooms, a full kitchen and a full bathroom.

LPA inspected the living room, dining area, kitchen, bedrooms, bathrooms, and backyard. The indoor and outdoor passageways were free of obstruction. The facility is under construction for an ADU adjacent to the lower level.
Furniture and furnishings were observed to be sufficient. Food supplies were sufficient of 2- days perishables and 7- days of non-perishables. Toilet, hand washing and bathing areas were observed clean and in operating condition. Showers were observed equipped with grab bars. Comfortable temperature is maintained and lighting is sufficient for comfort
Bed sheets, linens, and towels were observed to be sufficient and able to meet the needs of the residents at this time.

Central storage medication cart was locked, however. sharps and chemicals were observed to be unlocked and accessible to residents in care.

Hot water temperature was measured at 105 degrees Fahrenheit. Fire extinguishers were checked and last inspected on 4/17/2024.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/09/2024
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 05/14/2024 08:25 AM - It Cannot Be Edited


Created By: Murial Han On 05/09/2024 at 11:27 AM
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: HILLSBOROUGH MANOR
FACILITY NUMBER: 419210094

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 disinfectants, cleaning solutions, toxins were stored on top of the dryer,underneath the kitchen sink and in the garage areas were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure all toxins are locked and inaccessible to residents in care. The plan shall include staff training. The administrator/licensee will submit a copy of the signed and dated plan to CCL by 5/10/2024.
Type A
Section Cited
CCR
80087(g)(1)
Building and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

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 sharps stored in the kitchen drawer were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2024
Plan of Correction
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The administrator/licensee will develop a plan to ensure all sharps are locked and inaccessible to residents in care. The plan shall include staff training. The administrator/licensee will submit a copy of the signed and dated plan to CCL by 5/10/2024.
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: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024


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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: HILLSBOROUGH MANOR
FACILITY NUMBER: 419210094
VISIT DATE: 05/09/2024
NARRATIVE
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A review of (6) resident files was conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.

During today's visit, there are 2 residents present and 4 are attending the day program.

Based on observation, deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with administrator and program director. A copy of this report and the appeal rights were provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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