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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 419210116
Report Date: 11/20/2023
Date Signed: 11/20/2023 04:55:36 PM

Document Has Been Signed on 11/20/2023 04:55 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:SANGHA HOUSEFACILITY NUMBER:
419210116
ADMINISTRATOR:MARIA NAVARROFACILITY TYPE:
735
ADDRESS:3640 FLEETWOOD DRIVETELEPHONE:
(650) 515-4083
CITY:SAN BRUNOSTATE: CAZIP CODE:
94066
CAPACITY: 4CENSUS: 4DATE:
11/20/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:54 PM
MET WITH:Sally Dela CuevaTIME COMPLETED:
03:30 PM
NARRATIVE
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On 11/20/2023, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced Health and Check on staff and clients who were relocated due to renovation of the floor at the facility. LPA met with Administrator Sally Dela Cueva and explained the purpose of the visit.

On 11/10/2023, Licensing was informed, through voicemail left at desk duty number, by the administrator that all the clients will be temporarily relocated to Hyatt House Belmont due to the renovation of the floor. Administrator was advised by LPA Murial Han to submit a plan to her through email.on 11/13/23, and it was submitted on the same day. On 11/17/2023, administrator was advised that inspection needs to be done by Licensing before residents can move back to facility. Administrator was advised by Licensee that they won’t be able to extend stay in hotel due to budgetary concerns. On 11/19/23 facility relocated residents back to the facility.

Residents are currently in the facility resting upon arrival from Adult Day Program. Facility floor is now repaired and dried, no odors from from repair.

Deficiencies of the California Code of Regulations, Title, 22 are being cited on an LIC809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed. A copy of the report is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Grace Donato
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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 11/20/2023 04:55 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Grace Donato On 11/20/2023 at 02:38 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: SANGHA HOUSE
FACILITY NUMBER: 419210116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
11/21/2023
Section Cited
CCR
80022(j)

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(j) Any changes in the plan of operation which affect the services to clients shall be subject to licensing agency approval and shall be reported as specified in Section 80061.
This requirement was not met as evidenced by:
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Licensee to submit a plan on how facility will address future renovations and care for residents. Licensee to submit by POC deadline.
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Based on interviews, Licensee did not submit a change in operation plan to Licensing when residents were relocated during facility renovation which poses an immediate health, safety, or personal rights risk to persons in care.
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Under Appeal
Type A
11/21/2023
Section Cited
CCR80061(b)(1)(E)

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(b) Upon the occurrence, during the operation of the facility, of any of the events... (1) below, a report shall be made to the licensing agency within the agency's next working... In addition, a written report containing the information specified in (2) below shall be submitted to the licensing agency within seven days...(1)Events reported shall include the following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.

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Licensee to submit a plan of action regarding timely submission of incident reports or change of operation in the facility. Licensee to submit by POC deadline.
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This requirement was not met as evidenced by: Based on interviews, Licensee failed to notify Licensing in a timely manner that facility would need repairs and relocate residents temporarily which poses an immediate health, safety or personal rights risk to persons 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:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 11/20/2023 04:55 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Grace Donato On 11/20/2023 at 02:46 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: SANGHA HOUSE
FACILITY NUMBER: 419210116

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
11/21/2023
Section Cited
CCR
80064(a)(3)

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(a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation.

This requirement was not met as evidenced by:
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Licensee to submit a plan describing the duties and responsibilities of the Administrator to ensure that resident's health conditions and needs are addressed. The plan shall include monitoring staff and documentation, submitting plans or reports to Licensing in a timely manner. Licensee to submit by POC deadline.
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Based on interviews, Administrator failed to notify Licensing in a timely manner that facility would need repairs and relocation of residents to and from facility which poses an immediate health, safety, or personal rights risk to persons in care.
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Under Appeal
Type A
11/21/2023
Section Cited
CCR80063(a)

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(a) The licensee, whether an individual or other entity, is accountable for the general supervision of the licensed facility, and for the establishment of policies concerning its operation.

This requirement was not met as evidenced by:
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Licensee to submit a plan of action to describe how Licensee shall ensure compliance with CCR 80063. Licensee to submit by POC deadline.
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Based on interviews, Licensee/Administrator failed to notify Licensing when residents were relocated and proceeded to relocate residents without licensing approval which poses an immediate health, safety, or personal rights risk to persons 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:Grace Donato
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2023


LIC809 (FAS) - (06/04)
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