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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210105
Report Date: 03/21/2024
Date Signed: 03/21/2024 06:09:54 PM

Document Has Been Signed on 03/21/2024 06:09 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:FOCUS DAY PROGRAM IIIFACILITY NUMBER:
419210105
ADMINISTRATOR:YOLANDA T. RUIZFACILITY TYPE:
775
ADDRESS:755 CALIFORNIA DRIVETELEPHONE:
(650) 347-4780
CITY:BURLINGAMESTATE: CAZIP CODE:
94010
CAPACITY: 75CENSUS: 49DATE:
03/21/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Program Director, Jaime OrtizTIME COMPLETED:
12:10 PM
NARRATIVE
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On March 21, 2024 Licensing Program Analyst (LPA) Murial Han conducted an unannounced annual inspection. LPA met with Program Manager, Jaime Ortiz and Program Supervisor, Miguelito Macam and explained the purpose of the visit.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. During the visit, LPA observed day program clients to be split into 5 different groups with sufficient amount of staff members present in each group to assist clients.

LPA toured the facility activity rooms, conference room, and kitchen area. LPA observed 5 facility bathrooms to be clean and odor free. Hot water temperature was measured at 105- 109 degrees F. A comfortable temperature is maintained and lighting is sufficient for comfort.

Kitchen was observed to be clean and free from flies and pests. LPA observed chemical stored underneath the kitchen sinks were unlocked and accessible to clients.

Clients belongings/lunches were observed to be stored on shelved in the activity room and according to Program Manager, facility staff will prepare their lunches and pass them out at lunch time.

Smoke and carbon monoxide detectors were observed as operational. Fire extinguisher was last inspected on 8/17/2023.

A review of (6) client files were conducted and noted on the LIC 858.
A review of (4) staff files was conducted and noted on the LIC 859.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/21/2024
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 03/21/2024 06:09 PM - It Cannot Be Edited


Created By: Murial Han On 03/21/2024 at 11:21 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: FOCUS DAY PROGRAM III
FACILITY NUMBER: 419210105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
82087(a)(3)
Buildings and Grounds
(a) The program site shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (3) Disinfectants, cleaning solutions, poisons, and other items which 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 chemicals stored underneath the kitchen sinks were unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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The administrator/licensee will submit a plan to ensure all chemicals are locked and inaccessible to residents in care and will provide photos to CCL by 3/22/2024. The plan has to be signed and dated.
Type A
Section Cited
CCR
82087.5(a)(3)
Delayed Egress Devices
(3) Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.

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 facility did not have documentation to proof that drills were conducted since the re-opening of 3/2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/22/2024
Plan of Correction
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The administrator will submit a dated and signed plan to ensure drill are completed. The plan shall indicate when the drills will be completed. The facility will submit the plan to CCL 3/22/2024.
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: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 03/21/2024 06:09 PM - It Cannot Be Edited


Created By: Murial Han On 03/21/2024 at 11:21 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: FOCUS DAY PROGRAM III
FACILITY NUMBER: 419210105

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/21/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
82065.1(d)(1)
Personnel Qualifications and Duties
(1) Direct care staff shall receive a minimum of 8 hours a year of training, documented.

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 3 out of 4 staff files did not have documentation to proof that their annual training is conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2024
Plan of Correction
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The administrator/licensee will submit a signed and dated plan to ensure training is complete accordingly.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2024


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: FOCUS DAY PROGRAM III
FACILITY NUMBER: 419210105
VISIT DATE: 03/21/2024
NARRATIVE
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The following forms and documents were requested to be updated and submitted into CCL by 3/22/2024 in order to update this facility file:
  • LIC 308 (Designation of Responsibility)
  • Control Of Property (Lease Agreement)


The following deficiencies were observed and cited on the following LIC 809-D pursuant to Title 22 Rules and Regulations, Health and Safety Codes.

Appeal Rights were printed and a copy was given to the Program Manager and Supervisor.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2024
LIC809 (FAS) - (06/04)
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