419210099-7-31-2024-14-AS-MHAN-D7PSRE-20240731140614

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 419210099
Report Date: 07/31/2024
Date Signed: 07/31/2024 05:24:31 PM

Document Has Been Signed on 07/31/2024 05:24 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:	LOUVAINE HOME		FACILITY NUMBER:	419210099
ADMINISTRATOR:	AMY SORONGON		FACILITY TYPE:	735
ADDRESS:	1732 LOUVAINE DRIVE		TELEPHONE:	(650) 580-3896
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	4	CENSUS: 4	DATE:	07/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Manager, April Lucero		TIME COMPLETED:	02:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On July 31, 2024, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was greeted by the house manager, April Lucero and LPA explained the purpose of the visit. Facility's clinical consultant, Claire Ascalon arrived shortly and assisted with the inspection. LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. LPA toured the facility inside and outside including all of resident rooms, common areas, and kitchen area. The indoor and outdoor passageways were free of obstruction. Facility was overall clean and odor-free. Comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed four private resident rooms. Rooms were spacious and included all required furnishings. 1 full bathroom and a 1/2 bathroom were observed to be clean; equipped with paper towels, soap, grab bars, and non-skid mats. Extra linen was present. LPA observed medications, toxins and sharps were locked. 2 days for perishables and & 7 days non-perishable were observed to be present. Hot water temperature was measured at 105-109 F. Facility is equipped with smoke detectors and carbon monoxide detectors. Fire extinguisher were last serviced in May 15, 2024. Fire drill records were reviewed. 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. During today's inspection, there are no residents present as all of them were attending the day program.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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 07/31/2024 05:24 PM - It Cannot Be Edited

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: LOUVAINE HOME	FACILITY NUMBER: 419210099
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80072(a)(8)(E)1

Personal Rights

1. A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed. Bed rails that extend the entire length of the bed are prohibited except for clients who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above LPA observed 2 residents have 2 half bedrails by the head of the bed that the facility has obtained an exception from CCL, however, LPA also observed the same residents with 2 half bedrails by the foot of the bed without an approved exception from CCL which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/01/2024
	Plan of Correction
1 2 3 4	The administrator/licensee will submit a plan to ensure compliance and will provide a copy of the plan to CCL 8/1/2024.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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: LOUVAINE HOME	FACILITY NUMBER: 419210099
	VISIT DATE: 07/31/2024

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During the tour, LPA observed Resident #1 (R1) and Resident #2 (R2) have 2 half bed rails by the head of the bed and 2 half bedrails by the foot of the bed. Based on the documents provided, facility has obtained an exception for the 2 half bedrails by the head of the bed but not the bedrails by the foot of the bed. According to the Clinical Consultant, both residents require the bedrails due to their medical conditions.

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 the manager and the clinical consultant. A copy of this report and the appeal rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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